Time
Management
Tools
Chapter 18 of Nursing
Leadership and
Management by Patricia
Kelly
Introduction
Time Management

Time management is
“a set of related
common-sense skills
that helps you use
your time in the most
effective and
productive way
possible” (Kelly, p.
427).
Importance


Time management is
important for nurses on
the job and nurses in
their daily lives.
Time management
facilitates the
prioritization of care,
deciding on
appropriate outcomes
and the performance
of the most important
interventions first.
Overview
 The
Pareto Principle
 ABC
 Maslow’ Hierarchy
 End of Shift Reports/ Shift Plan
 Triangle Hierarchy
 Prioritization
and Delegation Exercise
The Pareto Principle “is a
strategy for balancing
life and work through
prioritization of effort”
(Kelly, 427).
"Lose an hour in the
morning and you will be
all day hunting for it"
Richard Watley (1864)
The Pareto Principle
 “States
that 20% of focused efforts results
in 80% of outcome results, or conversely
that 80% of unfocused efforts result in 20%
of outcome results” p. 427.
 Example: Reading textbooks while logged
into Facebook vs. reading textbooks and
focusing on what you are reading.
 Planning
your time leads to more
productivity.
 When you are frenzied and unorganized,
you will be less productive.
 Example: gathering items for a task like a
wound change. If you are going back
and forth from the supply room, you
waste time. If you gather your supplies
before you start, you will save time.
If you can achieve more
with focused effort why
don’t more people do
so?
• They might not know
how.
• They might enjoy the
attention.
• They believe they are
so busy they do not
have time to plan.
• They love the state of
crisis.
Incorporating the Pareto
Principle into Practice





Establish objectives
Prioritize
Eliminate tasks-delegate
Plan your time!
Work smarter, rather than making work
harder!
McLauchlan, C. (1997). Time Management.
Journal of Emergency Medicine, 14(5),
345-346
Conclusion
 The
Pareto Principle can be applied to
many situations at work and in daily life.
 There are times when an unexpected
event occurs and the Pareto Principle
might not be as effective as other tools.
ABC’s of
Prioritizationa guide to
determining lifethreatening
conditions
A- Airway
B- Breathing
C- Circulation
First priority: Life-threatening or
potentially life-threatening
conditions





Vital signs or level of consciousness have
potential for respiratory or circulatory
collapse
Risk to themselves or others
Can occur at any time during a shift
Not always able to anticipate
Need to monitor at risk patients to prevent
adverse reactions
Secondary priority: limb-threatening
and sight-threatening
ABC’s to determine lifethreatening
 Airway




Is it patent and open?
Any obstructions or foreign body?
Need for artificial for artificial airway
To maximize opening of airway
 Jaw-thrust
 Chin-lift
maneuver (suspected head or neck
trauma)
ABC’s continued
 Breathing

Adequate respirations?
 Rate,
rhythm, depth, chest rise, and work of
breathing
 Advantageous or absent breath sounds
 Pulse oximetry
 Use of accessory muscles, retractions or seesaw pattern

Provide ventilation
 Inadequate
respirations
ABC’s lastly

Circulation

Pulse
Slow, irregular, weak or rapid
 Bounding and full


Blood pressure


Skin color and temperature


High vs. low
Warms and dry vs. cool and clammy
Possibility of hemorrhage

internal or external
General Appearance, & LOC
 Level


of Consciousness
Is the pt alert and oriented? Confused?
Unresponsive?
Glasgow Coma Score can be used to
determine the LOC
 General

appearance-
How does the patient look and act?
Table 18-2 Top Priority with
Potential Threats to Their ABC’s

Respiratory





Cardiovascular




Airway compromise
Choking
Asthma
Chest trauma
Cardiac arrest
Shock
Hemorrhage
Neurological



Major head trauma
Unconscious/
Unresponsive
Seizures

Other









Major trauma
Major amputation
Major burn especially
involving airway
Abdominal trauma
Vaginal bleeding
Anaphylaxis
Diabetic with altered
LOC
Septic Shock
Child or Elder Abuse
Activity

Scenario 1


You are a nurse who has stopped at the scene of a motor
vehicle crash. You are first on the scene. As the ambulances
begin to arrive you direct which patients need to be
transported in which order.
Scenario 2

You are on duty at a small community hospital early one
morning when receive reports of a construction accident a
mile away. You call the physician on call and then prepare
to receive the patients. Three ambulances arrive
simultaneously with 5 patients.
Gurney, D. (2004). Exercise in Critical thinking at triage:
prioritizing patients with similar acuities. Journal of
Emergency Nursing, 30(5), 514-515. DOI:
10.1016/j.jen.2004.07.005
Maslow’s
Hierarchy
Page 20-21
SelfActualization
Morality,
creativity
Esteem Needs
Self esteem,
confidence,
achievement
Social Needs/Love and
Belonging
Interaction with others,
friendships
Safety Needs
Safety of the body, family, health
Safe working conditions, job security,
benefits
Physiological Needs
Breathing, food, water, excretion
Breaks, adequate salary, working conditions
Spend your time
according to your
needs, or your
patients needs.
End of Shift
Reports
Advantages and
Disadvantages
Face-to-Face Report
Advantages



Nurses get clarification
and can ask questions
The nurse giving report
has an actual
audience and tends to
be less mechanical
Nurses are more likely
to give pertinent
information than they
would give a tape
recorder.
Disadvantages




It is time consuming
It is easy to get
sidetracked and gossip
or discuss non-patientrelated business
Both oncoming and
departing nurses are in
report
Patients are not
included in the
planning
Walking Rounds
Advantages







Provides the prior shift and incoming
shift staff the opportunity to observe
the patient while receiving report;
staff can address any assessment or
treatment questions
Information is accurate and timely
Patient is included in the planning
and evaluation of care
Accountability of outgoing care
provider is promoted
Patient views the continuity of care
Incoming shift makes initial nursing
rounds
Departing nurse can show
assessment and treatment data
directly to oncoming nurse
Disadvantages


It is time consuming
There is lack of privacy
in discussing patient
information
After the shift hand-off report is accomplished,
the next step is to formulate the plan for the
shift. The nurse needs to look at the big
picture in regards to the assigned patients.
 Decide on optimal and reasonable outcomes
 Set priorities based on life-threatening
conditions, safety considerations, and
activities essential to comfort, healing, and
teaching
 Make assignments when possible to optimize
time and expertise- delegate tasks
 Determine timing of the necessary
interventions, whether they are flexible or a
completion time must be determined
Kaplan, B., & Ura, D. (2010). Use of multiple patient
simulators to enhance prioritizing and delegating skills
for senior nursing students. Journal of Nursing
Education, 49:7, pp. 371-377
In this study the authors investigated the use of
multiple patient simulators to help develop the
prioritizing and delegating skills of nursing
students. They sought to address the difficulty
new nurses experience when they make the
transition to being a practicing nurse, and need
high-level leadership skills. It is necessary that
they acquire not only knowledge, but the ability
to apply conceptual and critical thinking in
prioritizing and delegating care in the critical
setting.
In this study, the participants listened to an
audiotaped change-of-shift report on three
simulated patients, so they would not be able
to ask questions. This was to see if they would
attempt to collect more information through
the mock patient chart or patient assessment.
Of the three patients, one was stable, one had
potential for problems, and one had been
admitted at night and was considered
unstable. The nurse was supposed to prioritize
based on patient status, and staff competency.
The most urgent needs would be identified and
the nurse would have to delegate some of the
care.
The self-reported confidence in both
prioritizing and working in teams was
increased, as was the understanding about
how to prioritize and delegate care.
Following the implementation of this
program into the curriculum, students
voiced their desire to complete weekly
simulation exercises until graduation. They
stated that the simulation activity gave
them true insight into the shifts in
responsibilities experienced when bridging
the gap between being a student and a
practicing nurse
The Prioritization
Triangle
Do First Things First!


Nurses needs to come to terms with limited
resources that can happen in the hospital.
Example: someone calls in sick and there is no
replacement. It would be difficult to reinforce
teaching or discus home environment with a
patient that is getting D/C the next day but
you would perform life-saving interventions
because these would be the highest priorities.
The safety of patients and staff is most
important.
Kelly, P. (2012). Nursing Leadership &
Management (3rd ed.)
Being Able to Set a Priority for Patients and
Time Management Requires “Knowing”




A research article written by Catherine Litchfield and
Keri Chater (2007) followed new graduate nurses in a
neonatal unit and found:
When these nurses did not know the clinical condition
of different neonates, they felt unable to manage their
time because they had to spend more time looking for
information as well as learning how to care for the
neonates.
The nurses felt out of their depth, which caused them
to feel anxious about not knowing what to do for that
neonate and anxious that something would happen.
When the new graduate nurses gained knowledge,
they were able to manage their time more effectively
by prioritizing what was important, knowing what to
expect and knowing routines, which enabled them to
predict outcomes and made work easier.
The Prioritization Triangle





Contains four levels
Life-Threatening Conditions: Check ABCs
(highest priority/ foundation of triangle)
Potentially Life-Threatening Conditions (2nd
level of triangle)
Essential Safety Measures (3rd level of triangle)
Comfort, Healing, and Teaching (4th level of
triangle)
Kelly, P. (2012). Nursing Leadership &
Management (3rd ed.)
First Priority


Nurse should give first priority to levels one
and two (Life-Threatening Conditions and
Potentially Life-Threatening Conditions).
Patients who are at risk for respiratory or
circulatory collapse and harming themselves
are given high priority and should be
monitored all throughout the shift.
-ABCs
Kelly, P. (2012). Nursing Leadership &
Management (3rd ed.).
Second Priority


Being able to provide safe care to patients
and having a safe work environment for staff
is extremely important. Life saving monitoring,
medications, and equipment to protect
patients from fall and infection are essential.
Example: asking for help with turning or
moving patients, prevention of falls or pressure
ulcers.
Kelly, P. (2012). Nursing Leadership &
Management (3rd ed.)
Third Priority


This level includes comfort, healing, and teaching
and is essential to the recovery of the patients. If
these activities are not completed, the patient’s
recovery will be delayed.
Examples: interventions that relieve pain and
nausea, promote healing like nutrition,
ambulation, positioning, medication
administration, and teaching.
Kelly, P. (2012). Nursing Leadership &
Management (3rd ed.)
Overview




General time management strategies include an
outcome orientation, analysis of time cost and use,
focus on priorities, and visualizing the big picture.
Shift planning begins with developing both optimal and
reasonable outcomes.
Priority setting takes into account what is life threatening
or potentially life threatening, what is essential to safety,
and what is essential to the plan of care.
The shift action plan assigns activities aimed at outcome
within a time frame.
Overview Continued




End-of-shift hand-off reports include face-to-face
meetings and walking rounds.
The shift action plan is evaluated at the end of
shift by asking if optimal or reasonable outcomes
have been achieved.
Time wasters that might interfere with outcome
achievement include procrastination, inability to
delegate, inability to say “no,” management by
crisis, haste, indecisiveness, interruptions,
socialization, complaining, perfectionism, and
disorganization.
Quality time can be achieved by analyzing time
use and energy patterns.
Strategies to Enhance
Personal Productivity



Time management and organization can be
applied to daily activities
Nurses can create more personal time by hiring
someone else to do work and/or getting up one
hour earlier every day which totals 365 hours extra
each year.
Nurses can use downtime, for example, having
reading and writing materials available at all
times, listening to books on tape in the car when
traveling.
Kelly, P. (2012). Nursing Leadership &
Management (3rd ed.)
References





Kelly, P. (2012). Nursing Leadership & Management (3rd ed.).
Clifton Park, NY: Delmar Cengage Learning
Litchfield, C. & Chater, K. (2007). Can I Do Everything? Time
Management in Neonatal Unit. Australian Journal of
Advance Nursing, 25(2), 36-45.
Gurney, D. (2004). Exercise in Critical thinking at triage:
prioritizing patients with similar acuities. Journal of
Emergency Nursing, 30(5), 514-515. DOI:
10.1016/j.jen.2004.07.005
McLauchlan, C. (1997). Time Management.
Journal of Emergency Medicine, 14(5),
345-346
Kaplan, B., & Ura, D. (2010). Use of multiple patient simulators to
enhance prioritizing and delegating skills for senior
nursing students. Journal of Nursing Education, 49:7, pp.
371-377
A Nursing Team Leader Caring
for Multiple Clients
You are the team leader providing care for
six clients. The team includes yourself (RN),
an LVP, and a newly hired nursing assistant.






Mr. C, 68 y/o M with
unstable angina who needs
teaching for a cardiac
catheterization scheduled
this morning.
Ms. J, a 45 y/o F
experiencing chest pain
scheduled for a graded
exercise test later today.
Mr. R., a 75 y/o M with a 4day-old left sided stroke
Ms. S. an 83 y/o woman
with heart disease, a history
of MI, and mild dementia.
Ms. B, a 93 y/o F, newly
admitted from long-term
care with decreased UO,
ALOC and an elevated
temperature of 99.5F
Mr. L, a 59 y/o man with
mild SOB and chronic
emphysema
1.
2.
Which clients
should you assign
to the LVN?
Which client
should you assess
first?
1.
2.
3.
4.
Mr. C
Ms. J
Ms. B
Mr. L






Mr. C, 68 y/o M with
unstable angina who needs
teaching for a cardiac
catheterization scheduled
this morning.
Ms. J, a 45 y/o F
experiencing chest pain
scheduled for a graded
exercise test later today.
Mr. R., a 75 y/o M with a 4day-old left sided stroke
Ms. S. an 83 y/o woman
with heart disease, a history
of MI, and mild dementia.
Ms. B, a 93 y/o F, newly
admitted from long-term
care with decreased UO,
ALOC and an elevated
temperature of 99.5F
Mr. L, a 59 y/o man with
mild SOB and chronic
emphysema
Which of the
following tasks should
you delegate to the
nursing assistant?
1. Ask Ms. S
memory-testing
questions.
2. Tell Ms. J about
treadmill exercise
testing.
3. Check pulse
oximetry for Mr. L.
4. Monitor urine
output for Ms. B.
Close to the end of the shift, the LVN reports
that the nursing assistant has not totaled clients’
intake and output for the past 8 hours. What is
your best action?
1. Confront the nursing assistant and instruct
her to complete this assignment.
2. Delegate this task to the LVN as the nursing
assistant may not have been educated in
this task.
3. Ask the nursing assistant if she needs
assistance in completing the intake and
output records.
4. Notify the nurse manager to include this on
the nursing assistant’s evaluation.
Shortness of breath, Edema,
and Decreased Urine Output
Ms. J. is a 63 y/o F who is admitted directly to
the medical unit after visiting her physician for
SOB and increased swelling in her ankles and
calves. Her admitting DX is rule out chronic renal
failure (CRF). Ms. J states that her symptoms
have become worse over the past two to three
months and that she uses the bathroom less
often and urinates in smaller amounts. Her past
medical history includes HTN (30 years), CAD (18
years) and type 2 diabetes.
Ms. J. is a 63 y/o F who is
admitted directly to the
medical unit after visiting
her physician for SOB and
increased swelling in her
ankles and calves. Her
admitting DX is rule out
chronic renal failure (CRF).
Ms. J states that her
symptoms have become
worse over the past two to
three months and that she
uses the bathroom less often
and urinates in smaller
amounts. Her past medical
history includes HTN (30
years), CAD (18 years) and
type 2 diabetes.
Admission vital signs:





Temp: 97.8 F
BP: 162/96
HR: 88
RR: 28
Pulse ox: 91% on
room air
Admission lab tests to
be collected on the
unit include serum
electrolytes, renal
function tests, CBC
and urinalysis. A 24
hour collection for
creatinine clearance
has also been ordered.
You are the team leader, supervising an
LVN. Which nursing care action for Ms. J
should you delegate to the LVN?
1. Insert and intermittent catheter to assess
for residual urine.
2. Plan fluid restriction amounts to be given
with meals.
3. Check breath sounds for presence of
increased crackles.
4. Discuss renal replacement therapies with
the patient.
As team leader, you observe the nursing
assistant (NA) perform all of these actions
for Ms. J. For which action must you
intervene?
1. NA assists Ms. J to replace oxygen nasal
cannula.
2. NA checks Ms. J.’s vital signs after the
patient drinks fluids.
3. NA ambulates with Ms. J to the
bathroom and back.
4. NA washes Ms. J’s back, legs, and feet
with warm water.
You are supervising a new orienting nurse
providing care for Ms. J, who has had surgery to
create a left forearm dialysis access. Which of
the following actions performed by the nurse
requires that you intervene?
1. The nurse monitors the patient’s operative
site dressing for evidence of bleeding.
2. The nurse obtains BP reading by placing the
cuff on the right arm.
3. The nurse draws post-operative lab studies
from temporary dialysis access.
4. The nurse administers oxycodone by mouth
for moderate post-operative pain.
Assessment of Ms. J after dialysis reveals all
of these findings. Which assessment finding
necessitates immediate action?
1. Ms. J’s weight is decreased by 4.5
pounds
2. Ms. J’s systolic blood pressure is
decreased by 14 mm Hg.
3. Ms. J’s level of consciousness is
decreased.
4. Ms. J.’s temporary catheter dressing has
a small blood spot.
Six months later, Ms. J is readmitted to the unit.
She has just returned from hemodialysis. Which
nursing care action should you delegate to the
nursing assistant?
1. Obtain vital signs and post-dialysis weight.
2. Assess hemodialysis access site for bruit and
thrill.
3. Check and assess site dressing for bleeding.
4. Instruct patient to request assistance getting
out of bed.
Cardiovascular Problems
You are the charge nurse for the coronary step
down unit. Which patient is best to assign to an RN
who has floated for the day from the general
medical-surgical unit?
1.
Patient requiring discharge teaching about
coronary artery stenting prior to going home with
spouse today.
2.
Patient receiving IV furosemide (Lasix) to treat
acute left ventricular failure.
3.
Patient just transferred from the radiology
department after a coronary angioplasty.
4.
Patient just admitted with unstable angina and
who has orders for a heparin infusion and aspirin.
You are working in the ED caring for a
patient who was just admitted with left
anterior chest pain, possible unstable
angina or myocardial infarction. Which
nursing activity will you accomplish first?
1. Auscultate heart sounds.
2. Administer SL nitro.
3. Insert an IV catheter.
4. Obtain a brief patient health history.
A patient with atrial fibrillation is ambulating
in the hallway on the coronary step-down
unit and suddenly tells you, “I feel really
dizzy.” Which action should you take first?
1. Help the patient to sit down.
2. Check the patient’s apical pulse.
3. Take the patient’s BP.
4. Have the patient breath deeply.
A diagnosis of ventricular fibrillation is
identified for an unresponsive 50-year-old
patient who has just arrived in the ED. Which
action will you take first?
1. Defibrillate at 200 Joules
2. Start CPR
3. Administer Epi 1 Mg IV
4. Intubate and manually ventilate.
You are ambulating a cardiac surgery
patient who has telemetry cardiac
monitoring when another staff member tells
you that the patient has developed a
supraventricular tachycardia with a rate of
146 beats per minute. In which order will
you take these actions?
1. Call the patients physician.
2. Have the patient sit down.
3. Check the patients blood pressure.
4. Administer oxygen by nasal canula.