Article      March 2001


Our time management in patient care

Ramesh B. Navuluri


This article prints out as 7 pages.

Return to Front Page

Search this site

Awareness

Rationale

Responsibility

Action

Rhythm Model

Summary

References
 
 

 
      We find so much literature on time management that it is hardly possible to find time to assimilate all the thoughts, techniques, concepts, and analogies found there.  Additionally, one will hardly find any book on time management that is devoted to frontline staff exclusively.  Staff nurses, being the frontline staff in nursing, may have a hard time exploring, understanding, and adapting some of the time management techniques directed at managers.  I have made an attempt here to show how as staff nurses we can adapt some time management techniques in direct patient care.  After all, staff nurses are the Patient Care Managers in their own right, for the “buck of direct patient care” stops at the staff nurses’ level.  Staff nurses manage multiple tasks of patient care in a given time period, have the responsibility to delegate tasks to unlicensed assistive personnel, and are accountable for their actions as well as the actions of those under their supervision. Time can mean different things to different people. By having awareness of what time we need to focus on; considering the rationale for managing our time; taking responsibility for managing our time; and, finally, taking action, we can indeed manage our time. 
Awareness
     Newton said that time was absolute, and that it occurred whether the universe was here or not.  Later, Einstein said that time has no independent existence apart from the order of events by which we measure it (Smith, 1994).  Does it matter for us who was right?  For staff nurses, time means our shift.  To be more specific, it is an 8, 10, or 12-hour shift in patient care.  Our employers compensate us for “our time”.  That means, we sell our time, which in turn could mean that we own our time.
      According to the Webster’s New Collegiate Dictionary, to manage means (i) to handle with a degree of skill, (ii) to succeed in accomplishing.  Hence, time management means to handle time with a degree of skill.  Since we cannot view time as a concrete three-dimensional object independent of events, for us “our time management” means skillfully accomplishing the patient care events during our shift.
Rationale
     What kind of time do we own?  Are we selling the right quality of time?  Are we getting a profit from that sale, or are we just breaking even, or perhaps even incurring a loss?  How satisfied are our customers: the ultimate customers, our patients; and the intermediate customers, our employers.  The value of our shift-time is conditional, like a raw diamond.  The raw diamond does not attain its value until it is properly cut and carved.  Similarly, our shift time will not be valuable unless we turn it into valuable patient care events.  The patient care events become valuable when we fulfill those events effectively and efficiently.  By selling a valuable good, we can be sure of a satisfied customer, which can give us peace of mind, for there will be no “returns” of the goods.  By striving at productivity through effectiveness and efficiency in accomplishing the patient care events, we derive pleasure or happiness.  Hence, we want to manage our time to derive peace, productivity, and pleasure (Smith,1994).
Responsibility
     The focus of time management for us rests on two levels: temporal and spatial.  We need to focus on our patient care events during our shift.  There is no need to either extend or transfer this focus beyond the confines of our shift (temporal) or the confines of our work environment  (spatial).  Our focus on the management of the patient care events permeates throughout our shift, in the conference rooms when taking and giving reports, and in the patient rooms when delivering nursing care.  When we maintain focus on our time both spatially and temporally, regardless of where we are or what we are doing, we can complete the patient care events effectively and efficiently.
     Who can manage our time and the patient care events we complete in our shift?  Well, we own our time, therefore we manage our time. Who else, if anyone, can manage our time? What are the consequences of others managing our time? Patient care is a team event. We, the staff nurses, are the team leaders, or the managers of patient care. Nurses’ aides, unit secretaries, other departments’ personnel, the physicians, and the patients themselves as well as their families are part of the team.  The wisdom is that we should let everybody help us manage our time, but only to the extent that we never relinquish ownership of our time.  This serves two purposes: a) we do not lose ownership of our time and miss the consequent peace, productivity, and pleasure; and  b) we recognize and respect others’ ownership of their time, so  they, too, can reap their own benefits of productivity, peace, and pleasure.
Action
      By being aware of the meaning of time, the reasons for managing time and its concomitant events, the objects of our time and event focus, and the identity of our time managers, are we not ready to  manage our time? Yes, we are but how? The answer is in our heart!  Think of our heart rhythm: PQRST pattern.  Day in and day out, second in and second out, a heart beats rhythmically to manage the physiologic and homeostatic events assigned to it.  Beat after beat it maintains its rhythm.  Between beats it rests too.  Occasionally it corrects itself with ectopic beats, and adapts itself to emergencies and hormonal responses.  It works as part of a team with other organs.  It does not try to give ownership of its time to other organs, neither does it claim the ownership of time from other organs.  We all know what happens when one organ has to compensate for the changes in functioning of other organs, or  too many ectopic beats are occurring.  Similarly, we can manage our patient care events in a rhythm.
Rhythm Model
      Some patient care events such as report taking and giving, assessments, administration of medications, feeding patients, or performing blood sugar checks must occur at specific times during a shift, while some other events such as bathing patients, doing wound care, checking orders, or answering call bells can occur at any time during a shift.  The number of events per shift per staff nurse varies greatly depending on several factors of which we are aware.  However, like in a normal sinus rhythm where the frequency of  beats per minute could be 60 to 100, the number of events in a shift could vary and yet could be accomplished “normally” within the limitations of the variations of our own personalities and abilities. Also, not all arrythmias are dysarrhythmias.  Similarly, there could be emergencies in patient care events which we have to attend to there and then, which could be like ectopic beats, without necessarily disturbing our rhythm in managing the patient care events during a given shift. The arrythmia becomes a dysarrythmia when too many ectopic beats have to be accommodated in a given period.  For example, one of our 7 or 10 patients is having a seizure, another is having difficulty breathing, yet another is needing assistance to go to the restroom, and we are on the phone taking report for a new admission from the emergency department.  Lo and behold, the lunch trays have been delivered on the unit at the same time.
      We can effectively and efficiently manage our time by recognizing that the occurrence of patient care events can be viewed in a rhythmic fashion. There can still be a change in the frequency of the events due to changing priorities or our own abilities to complete the patient care.  Emergencies may still not strain our ability to manage patient care.  We can derive some insight into time management in patient care from the general  principles of time management.  As when characterizing cardiac rhythm, we will use the mnemonic PQRST…U to discuss the application of various principles of time management  to patient care.
P for Prioritize
      Prioritization of patient care events enables us to accomplish the most important events first.  We should not, however, lose sight of the time we own, 8-10-12 hours of the day.  We have to accomplish the top priority events as well as the low priority events within that time we own.  We need to recognize the events controlled by us, and  those controlled by others.  We need to identify the events that must occur at specific times, and events that can be taken care of during a reasonable period later during our time.  The events like assessments, charting, baths, IV tubing and dressing changes, checking orders, and notifying results to MDs can be mostly controlled by us.  The timing of emergencies, patients’ and families’ demands, admissions, etc. are usually controlled by others in the team.  There is no single straightforward rule that can be applied to prioritize patient care events.  By critical thinking and invoking the questions of what, where, when, why, who, and how of any event, we can come up with a rationale for assigning priorities.  Once we assign the top priority to an event, we must accomplish it right there and then.  The difference between a top priority event and the next one in priority could be a matter of minutes.
      For example, consider two events.  One event is that one of our patients is in the rest room and calls for help to get back to bed.  While we are on the way to help that client, the call bell next door is on.  Since the first call bell from the bathroom has an urgent pitch on it, I would say, we go there.  Once we see the client not being in any distress and that all that client needs is to get up, yet can stay on the commode for a few more minutes, we can turn the call light off and tell the client that we will be back in a couple of minutes.  Then we come back to client next door.  The client says that his or her IV is hurting.  We assess that it has infiltrated.  We can turn the IV line off, a top priority then, and tell the client that we will be back in a few minutes to discontinue it and start another IV. Then we go back to the client on the commode, and help that person to go to bed.  After that we return to the client with the stopped IV, and discontinue it.  We “bought time” from both the clients and accomplished the events successfully and skillfully to the satisfaction of both of them.
      The “buy time” concept is explained further.  If we can break events into simpler tasks (Kent, 1997), they become more manageable.  For example, a patient’s IV is infiltrated.  The event to be accomplished here is to change the IV. This event can be broken down into simpler tasks: discontinue IV, stop bleeding, get new IV tubing primed, and start another IV. We can “buy time” between the tasks of stop bleeding and priming new IV tubing, and between priming a new IV tubing and starting another IV, if needed.  The question then is whose time are we buying? We are buying time from the patient.  The patient expects us to complete the event.  If we complete the event as promised, the patient is happy.  The risk in this transaction is “trust”.  If we complete the event as promised, we can get our “trust” back, otherwise we lose it.  Additionally, it helps if we recognize that time is the most perishable of all commodities.  If we buy it and don’t use it as planned, it perishes. Once it perishes, we cannot trade it back for our “trust” from the patient.  The relationship with our patient then becomes tarnished.
      We can also “buy time” from ourselves, and from the other team members depending on the event, depending on the need for us to have extra time at any given instance, and depending on the urgency of the event.  The price we pay could be the trust we want to build in others, enhancement of our own integrity, or even a positive display of our own work ethics.  Additionally, by breaking the events into simpler tasks, each task can be assigned a different priority if need be, and some of those tasks can be delegated effectively to aides, to unit secretaries, to the families, to the patients themselves.  This concept of breaking the event into simpler tasks, and assigning them different priorities, and delaying the completion of low priority tasks later can be called “creative procrastination” (Hanks, 1986; Hobbs, 1987).  However, it is our responsibility as patient care managers to ensure that the delegated tasks as well as the delayed tasks are completed within our own time. So, we need to monitor and follow-up on each task continually.
      By breaking the events into simpler tasks, it is also possible to deal with interruptions effectively.  There are necessary interruptions and unnecessary interruptions and we all know what each type is.  For example, a phone call from the laboratory to notify us of a lab result is a necessary interruption.  Charles Hobbs (1987) wrote that necessary interruptions are not time wasters.  Middle level managers get interrupted every eight minutes, and the senior managers get interrupted every five minutes, he wrote.  How often do you think we, the patient care managers, get interrupted? Sometimes it seems like every minute!

Q for Question
      Question the events and the tasks in terms of effectiveness, efficiency, and efficacy, and keep the focus on those aspects continually.  The effectiveness (Hanks, 1986) of an action means the extent to which it produced the intended outcome. When we question the why of an event in our plan and come up with a satisfactory answer and accomplish it, we become effective.  The efficiency of an action means accomplishing it with the least possible expenditure of time and effort. Learning ways to improve how we accomplish those events and accomplishing them as fast as we can, we achieve our efficiency.  The efficacy of an action means the ability or skill to produce an effect.  We have to continually strive to learn new skills, and improve our current skills by all the means we can so that we can be efficacious. 
     Consider the patient care event of assessment.  The assessment can be done in 2 hours, in 2 minutes, or in any amount of time in between.  The assessment is an effective event, for we can easily answer the question, why assessment?  We are efficacious because as staff nurses we have the ability to do assessment.  Now, what is remaining is to be efficient.  When we know how complete an assessment, and when there are no other demands on us during the period we have allocated for assessment we can be efficient.   But, we all know that it is not possible.  The minute we begin our shift, we already have several events planned, several urgencies are coming our way, and demands from other team members await us.  One way to deal with this dilemma is to break the assessment event into simpler tasks.
      By questioning similarly, we can avoid  creating “monkies” (Blanchard, Oncken & Burrows, 1989) for ourselves and for others. “Monkies” are situations that come about as a result of our own failure to do a task right the first time.  For example, consider the event of insertion of a nasogastric tube in a patient with the diagnosis of drug overdose.  What is the task? Insertion of an NG tube.  Why? To prevent aspiration.  How are we going to accomplish this?  By connecting it to suction.  Suppose we fail to connect the tube to suction after insertion and that the patient eventually aspirates.  Now the effectiveness as well as the efficiency with which we inserted the NG tube have no meaning. Consequently, the patient’s stay in the hospital is extended.  We have created a compromised patient, an angry family, a frustrated physician, and an unhappy supervisor.  We have thus created “monkies” for ourselves to deal with during our time, and also we will be shifting the responsibility of dealing with them to our colleagues in the subsequent shifts.  Thus, by continually questioning ourselves about the events to determine their effectiveness, efficiency, and our own efficacy vis-à-vis those events, we could be effective managers of our own time.

R for Re-check
      By re-checking the unfinished tasks or events as soon as we can, we can efficiently manage our time.  Before we can return physically to a leftover task, we have to mentally return to that task.  Mentally re-checking tasks is the essence of maintaining focus. As discussed earlier, we need to focus both spatially and temporally. By quickly establishing a rapport with our patients at the very beginning of the shift, we get a mental image of our patients.  We can even try to create a pigeonhole box in our memory with each of our patients representing a hole, and the events pertaining to each particular patient can be sorted into the respective hole. This exercise will be futile if we do not return to those holes periodically to find what is yet to be accomplished.
     To extend this concept, we can create several windows to suit our needs.  In each window we can a put a different pigeonhole box.  Such boxes could be designated according to the team members, or according to the major tasks.  For example, have a box for the MDs we are going deal with during our shift. When we see an MD, check the window with the box for MDs.  If there is some task or event in the hole to be taken care of with that MD, we take care of it there and then.  We can erase those windows, recreate them, modify them, enlarge them, or shrink them as we need from time to time. The key to successful use of these windows and pigeonhole boxes is to re-check them periodically and complete the left over tasks as soon as we can.

S for Self-reliance
      Ralph Waldo Emerson wrote, “isn’t it interesting how other people know my duty better than I know it?”  If we are clear in our minds what we can do and we cannot, what we can control and what we cannot, we can organize ourselves better and manage our patient care events effectively and efficiently.  Charles Hobbs (1987) identified five categories of events:

(1) events we think  we cannot control, and we cannot;
(2) events we think we cannot control, but we can;
(3) events we think we can control, but we cannot;
(4) events we think we can control, but we do not;
(5) and events we think we can control, and we can and will.
He suggested that we can deal with these events by adaptability, persistence, realism, resolve, and control respectively.  Let us apply these principles to our patient care events.
     We cannot control the timing of admission of a patient from the emergency department to our unit.  The best way we can accommodate this event is by being adaptable through revision of priorities.  We think  we cannot control the events delegated to the nurses’ aides because they have tasks assigned to them by our colleagues.  But if we are persistent, by pulling them with us instead of pushing them, we can control those events.  President Dwight Eisenhower once demonstrated the art of leadership by using a string. He would place the string on the table and say, “pull the string, it will follow you wherever you wish.  Push it, and it will go nowhere at all” (Treat, 1986).
     Coming to the events we think we can control, but cannot, think of some examples that could have happened to any of us.  Think of an event such as notifying the laboratory technician to come and draw blood from one of our patients stat, and the time it sometimes takes for a tech to arrive.  How do we deal with such a situation? Maybe realistically, maybe not!  If we could be realistic by recognizing that other personnel could be attending to other important tasks, can we not  manage such an event differently and efficiently!  By showing concern for others through a supportive attitude, not being arrogant, not intimidating, and through effective communication we can accomplish these tasks efficiently.  When we realize that the accomplishment of the event is not in our control, we may even take some time to either draw the blood sample ourselves. 
     We know we can control the events such as changing IV tubing after 72 hours, or passing warm wash rags prior to serving meals, or teaching a patient on some important medication, but sometimes we don’t.  We rationalize for not accomplishing an event.  Charles Hobbs (1987) noted that rationalization, not interruptions, is a barrier to time management.  Unhealthy rationalization takes us away from the reality, clouds our thinking, and makes us lose control.  Healthy rationalization with the purpose of evaluating why we have failed to accomplish a particular event may provide us some insight that may improve our efficacy.  Once we find the drawbacks within us, we should strive to resolve them for our own good, thus enhancing the value of our own time. 
     We should control those patient care events, which we can control.  If Vilfred Pareto’s 80/20 rule (Hanks, 1986) is applicable to patient care management, it will read as “ 80% of the patient care events are accomplished in 20% of the time.”  I would say that those 80% of the events are those that are probably in our control.  The remaining 20% of the events are probably the other four kinds of events hitherto discussed.  Can we effectively and efficiently use the 80% of our time to adapt, to persist, to realize, and to resolve those events as they occur, as they are identified, as they come our way?

T for Treat
      As Tom Wicker (Hanks, 1986) observed, no person is truly free who is not permitted occasionally to be irresponsible, nor is any institution.  Treats are also a part of the rhythm of life. It is okay to take breaks, be “irresponsible” at times!  But we should treat ourselves only after we have managed the patient care events up to that time.  In our rhythm model we have provision for such brief intermissions.  Yet, we know what happens and what we do when there are long pauses in the rhythm.  But, we should remember that in those brief interludes we should not lose focus of the events.  Using break times to refocus on what is yet to be accomplished is part of the rhythm of the shift.
 How else can we treat ourselves?  We can treat ourselves to be effective.  We need to treat ourselves to have highest personal integrity, to commit to excellence, to build trust in others, and to have concern for others.  We need to treat others on the team with respect, concern, trust, care, cooperation, and compliments (Hobbs, 1987).  By so treating our team members and ourselves, we foster a homeostatic environment for our rhythm in time management to sustain.

U for "u" do it!
       Though we are provided with assistance from unit secretaries and nurses’ aides in carrying out our patient care management responsibilities, let us acknowledge that they assist not one of us, but several of us.  Similarly, other members of the team such as respiratory therapists, laboratory technicians, radiology technicians, dietary department personnel, and pharmacists provide their services to several other units in the hospital.  Sometimes, if we wait for them to complete some tasks for us, we may even forget about them by the time they come around to do those tasks.  For example, an MD writes an order for a diet change for one of our patients.  The unit secretary has seven other charts in waiting on which s/he has to note the orders. Our patient’s diet change must be communicated to the dietary department before it can happen. If we have time, we may as well activate the diet change order, sign the chart, and put it back in the rack.  Think about what that act by us does to our own time management, to the team spirit, and to the patient.  We encounter similar circumstances at different times involving different tasks.  We may not be able to “just do it” on all occasions, but we sure can at times.

Summary
     By prioritizing events, by breaking events into simpler tasks, by “buying” time and using it, by focusing on efficacy, effectiveness and efficiency related to accomplishing the patient care events, by organizing the events in our memory windows in pigeonhole boxes, by re-checking our pigeonhole boxes periodically, by delegating certain tasks to other team members, by being self-reliant, and by treating others and ourselves with integrity, courtesy, and respect we can manage our time efficiently in achieving quality patient care.  By recognizing that the patient care events can be viewed to occur in a rhythmic fashion we can channel our activities in tune with that rhythm.  The rhythm could be different for each one of us, on different days for any of us, or changing its tempo during different time periods in a shift.  Yet as long as we strive to prevent it from getting into a dysarrhythmia we can manage our time skillfully in accomplishing quality patient care.
 

References

Smith, H. W. (1994). The 10 natural laws of successful time and life management: Proven strategies for increased productivity and inner peace. Warner Books Inc., New York.

Kent, C. (1997). Organizing hints & tips. D. K. Publishing Inc. , New York.

Hanks, K. (1986). Up your productivity. William Kaufmann Inc., Los Angeles.

Hobbs, C. R. (1987). Time power.  Harper & Row Publishers, New York.

Blanchard, K., Oncken Jr., W., & Burrows, H. (1989). The one minute manager meets the monkey. William Morrow and Company, New York.
 
 
 
 
 
 
 

 

 Books on this topic: (click on book to order or examine at Amazon.com)

The One Minute Manager Meets the Monkey
by William, Jr. Oncken, Hal Burrows, Kenneth H. Blanchard

Getting Things Done: The Art of Stress-Free
Productivity
by David Allen

Unwinding the Clock : 10 Thoughts on Our Relationship to Time                    by Bodil Jonsson, Tiina Nunnally

Last updated May 21, 2001
 

Copyright© 1999, 2000, 2001 by Graduate Research LLC.  All rights reserved.