1. Kohtz, Cindy EdD, MSN, RN, CNE
  2. Gowda, Connie MSN, RN
  3. Guede, Pamela MSN, RN


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.

Article Content

THE WORK OF NURSES in the acute care setting requires disciplined 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 independently and coordinating the care of a group of patients.1,2 Nurse preceptors, nurse educators, and nurse leaders play an important role in helping them learn to manage time, prioritize responsibilities, and delegate 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 prescriptions, the cognitive process of stacking 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



Developing a routine is a good beginning to developing effective time-management skills. Routinization 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 scheduled medications; documenting; and providing patient handoff to the incoming nurse. When routinizing tasks, consider both the sequencing of expected activities and the duration 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 organizations, this document may be a computer-generated snapshot sheet of each patient that the nurse simply personalizes with handwritten entries of uncompleted tasks. Whatever 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 educators 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 Additionally, 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 benchmark 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 prescriptions 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 example, dressing change supplies, suction 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, 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 nursing 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 interruptions from call lights or other distractions. Point-of-care documentation 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 medications 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 documenting medications will increase the time needed. Other factors, such as number of assigned patients and number and route of medications, will also affect the time needed. Consider medication-related activities a fixed time commitment because each organization has a specified window of time in which scheduled medications must be administered. One useful strategy is to make the most out of each visit to the patient and to bring scheduled medications during initial 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 professional practice expand for NLRNs coordinating the care of a group of patients.5 Nurse leaders can use the following two hierarchies of prioritization to teach new nurses how to manage multiple, concurrent activities.


The CURE hierarchy uses the acronym CURE to prioritize competing patient needs as follows.12


* Critical patient needs. These are situations where immediate intervention 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 healthcare provider's prescription prior to implementation.


* Routine patient needs. These include, but aren't limited to, performing physical assessments and administering medications.


* Extras. These are activities performed by the nurse that, while not essential, promote patient comfort. Examples include providing the patient with a warm blanket or performing hair care.12



A second hierarchy of prioritization titled the normative hierarchy of nursing tasks closely mirrors the initial sequencing of activities outlined in the CURE hierarchy: clinical emergencies, highly uncertain situations, and pain and core responsibilities (completing patient assessments, administering medications, performing dressing changes and treatments, and admitting and discharging patients).12,13 In addition, this method follows core responsibilities with other nursing tasks: relationship management activities such as explaining the unit routine to patients and families; documenting, helping coworkers, and providing patient and family teaching; system improvements such as organizing and restocking supplies; and personal time for meals, breaks, and social interactions.13



While developing a routine and prioritizing nursing activities are fundamental to effective time management, interruptions do occur. Nurses average slightly less than six interruptions per hour. Additionally, 54% of these interruptions occur while the nurse is involved in medication administration, increasing the risk of medication errors.14 Appropriate delegation of tasks can minimize 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 Council of State Boards of Nursing proposes "Five Rights" for successful delegation: right task, right circumstance, right person, right direction/communication, and right supervision.15 In applying these five rights, follow the rules and regulations of the state's nurse practice act and the facility's policies and procedures regarding delegation and role expectations.16


Delegation works best when the nurse and UAP have a positive working relationship that includes ongoing and timely communication and a shared desire to collaborate.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 agreement 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 overwhelming 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 willingness 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 experience serve nurses well throughout their careers.5




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