How I've learned to be a more efficient nurse

Staffing sucks lately at my hospital, and from what I read and see, it sucks everywhere. I thought I would post about the stuff I've hammered out in my first 6 months on the floor that has helped me deal with too many tasks and too little time. Clinicals do not prepare you for being a nurse because you have just a few patients who largely are not critically ill (if they are, they don't trust them to you alone). So you go from that to, in my case, having four critical care patients solo. Zoiks! First, and most important, is this premise: if I start getting that "oh shit" feeling like I'm running around miscellaneously completing tasks because I'm overwhelmed, I stop. Right then. And make a plan. Because that feeling leads nowhere but to chaos and panic.

Second, and this is related: I've learned to prioritize a LOT more than when I came right out of school. Yes, I have a task list and a bunch of stuff that needs to get done. I will attempt to do it all. However, The Big Picture trumps the task list for me now. I no longer leap out of my chair after getting report and start crossing stuff off my list. I take an extra 15 minutes to look at my monitors (after finding an hour into my shift that one patient had been off leads for 3 hours), read through the last day's orders in the physical chart (ever missed a "hold PM Coumadin" order that day shift didn't note even though they said they checked the chart?), and check the discharge planning---this way I know where my patient is headed and at least what went on specifically that day to help him or her get there. This also prevents terrible surprises at 3 AM when I have time to do an in-depth chart check and realize there was a missed order for serial EKGs all night or something.

Third, I schedule the meds and lab draws/tasks I need to get done. My report sheet has hourly intervals at the top of each patient section, and I fill them in. Example: patient A has meds at 8:00 and 10:00; entry on my sheet will be "9p meds." If my patient has a 1:00 Lovenox injection and I'm doing 8, 12, and 4 vitals, I write "12:30 VS/meds." This is the vital clustering of tasks that prevents the scattershot running around trying to get stuff done and also lets my patients get some more sleep. I think night nurses forget how important the body's rhythms are because we ourselves don't have any, but I don't want to be giving anyone ICU psychosis if I can help it. Sleep is important for healing. But I digress.

Fourth, I go around and fill my patients in on their schedules for the night. Example: "I will have pills for you at 9:00, and when I come in with those I will have time to help you get ready for bed. I will be waking you up around 1:30 to take your vital signs and give you medications, and when lab wakes you up, probably around 5, I will come take your vital signs again. Between those times, I will poke my nose in about every hour, but if you are asleep I will not wake you up. If you need something between those times, feel free to use your call light, and I will come as soon as I can; give me about 10 minutes before you call again, because I am caring for several other patients tonight."

That last part is the magic part. If patients KNOW I'm going to be in regularly throughout the night and that I'll be there as quickly as possible given that I have a couple of patients, they seem to relax. At first I didn't want to mention having multiple patients because I thought it sounded like an excuse or as if they shouldn't bother me because I had more important things to do, but they're not stupid. They can see how busy we are.

I'm sure the nursing veterans have way better tips than these, so share, please! This stuff probably seems obvious to experienced nurses, but no one taught me how to be efficient. Nursing school taught me how to exhaustively focus on details, and that isn't the skill I needed.