Nursing practice has become a complex endeavor. New registered nurses are often overwhelmed by the details of practice and struggle to set priorities as they make the transition from assignment with a preceptor to independence. Orientees have choices to make throughout a shift and often struggle with what to do first. Preceptors voiced concern that orientees needed more support and mentoring in developing strategies for establishing priorities and sequencing nursing actions. Could the Preceptor Council share strategies with unit preceptors to help build skills early in the orientation process?

LITERATURE REVIEW

A review of the literature focused on management, delegation, critical thinking, and care delivery themes. The article that provided the group with the clearest and most practical understanding of prioritization came from Hansten and Washburn (2001). The authors presented a model for developing thinking that can change the way a nurse looks at a shift and redirect perception of the work to be done. The authors advocated moving away from a checklist of tasks to a vision of patient outcomes, established by collegial relationships with the healthcare team and a partnership with the patient. This is a more professional way of viewing the workday and facilitates discernment of priorities. An additional article that was helpful presented the concept of a nurse's pacing throughout the shift as similar to a beating heart that changed rhythm according to environmental demand. This metaphor is rich in lessons to guide nurses' choices and activities during a shift (Navuluri, 2001). Research on primary care delivery helped to review patient-focused care versus task-focused care (Lundgren & Segesten, 2001). Another resource was the American Association of Critical Care Nurses preceptor handbook that provided a screening tool to determine what was of critical importance to address first (Alspach, 2000). Finally, Benner's (1984) work on role competencies and the seven domains of nursing provided valuable information for the project. Benner's studies advise a global view of the care unit and the teamwork required to prevent periods of overload.

THE PROJECT DEVELOPMENT

After a general review and discussion of the literature, the representatives of the 10 medical specialty units that comprise this specialty preceptor council decided to develop learning stations that would present perspectives and strategies on the prioritization of nursing time. The representatives developing the stations would seek and read relevant literature, develop the concept, and staff a station in a drop-in preceptor forum. Ideas were discussed with representatives' unit preceptor committees and brought back to specialty committee work sessions. This process provided an opportunity to relate literature to practice and make sense of observations. The ideas were then translated into games, posters, or visual presentations that were set up as interactive learning stations. Preceptors attended this specialty preceptor forum then tried using the ideas with their orientees. Representatives asked for reports of orientee responses on their units.

Station 1: Six Steps to Refocus Attention From Tasks to Outcomes (Hansten & Washburn, 2001)

1. Think critically. "Use intuition, creativity, logic and analysis as well as expert clinical judgment" (Hansten & Washburn, 2001, p. 2).

2. Plan and report outcomes. Plan the day with the patient by naming desired patient outcomes. Report these in a shift-to-shift report instead of tasks.

3. Make introductory rounds. Patients are reassured about nurses' commitment and competence when they introduce themselves, assess status, and show themselves to be knowledgeable as professional care planners intent upon continuity of care.

4. Plan in partnership with the patient. "RNs spend 3-5 minutes at the bedside early in the shift to discuss proposed shift objectives and to plan long-term goals. This event becomes the nucleus of the assessment, planning, interventions and evaluation processes, and it ensures that the nurse and the patient are working toward the same goals" (Hansten & Washburn, 2001, p. 3).

5. Communicate the plan. Help all team members identify the plan and know how important each of them is to this plan's success.

6. Evaluate progress. Meet several times throughout the shift to determine how it is going. Reprioritize as necessary. Check each team member's perception of progress and purpose (see Figure 1).

Station 2: Four Ps When Working in a Team (Hansten & Washburn, 2001)

The ideas provided by the four Ps list (see Figure 2) were discussed at the station, highlighting how to work effectively with patient care assistants (PCAs). This includes the purpose of the patient's hospitalization, the picture of how the patient should look at the end of the shift, the plan for achieving desired outcomes, and the part that each individual will play in the plan. These are agreed upon at the beginning of the shift and reshuffled several times afterward, as priorities shift, patients are discharged, and new patients admitted. Too often, PCAs perform tasks without recognizing their contribution to the greater good. Because most of the units have a mix of approximately five nurses to each PCA, PCAs are at risk of trying to assist too many RNs or are left with no one to truly direct the activity. When working with a team, be sure that each member understands the purpose, picture, plan, and part to be played in the care for each patient.

FIGURE 2 Four

Station 3: PQRSTU (Navuluri, 2001)

Navuluri (2001) discerned that a nurse functions much like a beating heart. There is a steady, reliable rhythm that could be speeded up to cover crisis and overload. The nurse could maintain this accelerated pace briefly but needs to drop back into a more moderate pace such that fatigue and stress would not impair mental acuity and physical stamina. Using the cardiac algorithm, the author gave nurses a mnemonic to help guide the pace of work throughout a shift (see Figure 3).

FIGURE 3 PQRSTU.

P: prioritize

Identify what can be controlled and order those interventions using critical thinking. Break tasks into smaller, simpler tasks, identifying those that need to be done quickly.

Q: question

"Question events and tasks in terms of efficiency, effectiveness, efficacy[horizontal ellipsis]" (Navuluri, 2001, p. 4). Ask which monkeys (time wasters) are created by not doing things correctly the first time (Blanchard, Oncken, & Burrows, 1989).

R: recheck

Mentally recheck on unfinished care, then physically recheck on anything requiring attention and follow-up.

S: self-reliance

Control what can be controlled. Adapt to the demands of what cannot be controlled and work through problems with persistence.

T: treat

Take a break when safely able to reenergize and reestablish a comfortable rhythm. Treat all team members with respect.

U: "u" do it

Sometimes, when teammates and colleagues are swamped, just do what is really assigned to another and move on.

Station 4: Buying Time

Forum participants played this game in pairs with the station preceptor, who posed situations and distributed play money. Decisions on the expenditure of money for time resulted in a deficit or success at the end of the "shift." The activity highlighted the consequences of failure to delegate or to rely on the contributions of other team members, inappropriate delegation, or failure to adapt to the workload (see Figure 4).

FIGURE 4 Buying Time.

The game

The concept of a personal money budget was applied to time management. Time was given a dollar value. An individual starts the day with money and an assignment sheet. Money is spent as nursing care activities are completed. Game participants have "money" from licensed practical nurses, PCAs, and patient escorts, as well as from the family members of patients, to "spend." The objective is to end the day with no money, showing wise expenditure. As the day went on, the nurse had to determine where to spend the money and how best to use resources. At times, participants had to borrow money from other RNs but then paid them back. As the list of care activities was completed, the moderator would describe a clinical situation that may occur at the end of the day to test the preceptors' priorities. Participants could negotiate with the family, pass on to the next shift, delegate to others, trade services with others, or let others know the needs toward adjustment of energy distribution. The goal of this game was to help preceptors focus on deliberate approaches to prioritization that could be used with orientees. The game was based on concepts of Benner's (1984) workplace competencies and how to adjust to shifts in workplace demands. This game forced nurses to weigh priorities and to delegate. The forum preceptor director of this activity had two scenarios to distribute, slightly different in time demands that would mimic the clinical setting. The following is an example of one of these scenarios. The preceptor distributed money (time) and read the cost (time demand). Participants paid the money from one of three stacks of money (time): their own, that of other RNs willing to help, and PCA money. The participants were trying to break even at the end of the day (see Figure 5).

FIGURE 5 Direction for Participants.

Summary of game concepts

This game stresses the importance of investing RN time where it is needed most and delegating or swapping services when possible. It helps new orientees focus on how they can direct their own activity to accomplish all that is needed in a shift. In the game, as in actual clinical time, sometimes, there are demands that exceed the budgeted time. Then, there ensues a discussion on what can be left undone, passed on to the next shift, or given to the family to follow-up on. This allows nurses to direct energy to priority matters and get away from the work list that is mentally generated at the beginning of the shift before any crises or stresses have occurred.

Station 5: Eliminate Monkeys (Blanchard, Oncken & Burrows, 1989)

Human nature being what it is, some people try to take shortcuts and hope things will work out even though they know that a certain technique or planning would yield more reliable results. If a person can identify procedures that usually do not work without consulting directions, an expert, or carefully planning each step, time can actually be saved because there is no need to fix errors. Examples of this in the clinical setting might include nasogastric tube insertion (get the right size the first time, measure, position correctly), tubing changes when patients have surgical IVs and multiple drips, and patient transfer using proper equipment and technique (see Figure 6).

FIGURE 6 Eliminate Monkeys.

Station 6: Five Fs for Prioritizing (Alspach, 2000)

1. Fatal: elements of the job that must be done in a timely way because failure to do so could cause death or injury

2. Fundamental: elements of the job that are essential to the professional role definition

3. Frequent: elements that must be performed repeatedly

4. Fixed: elements that must be done within certain time frames

5. Facility: elements of the job set as standards by the organization (Alspach, 2000, p. 77)

The Five Fs (see Figure 7) can be used to evaluate priorities during a shift and indicate what situations prompt a reevaluation. They provide a format to discuss needs for reassessment and flexibility and to evaluate at the end of the shift how prioritization served the patients. These activities allow the nurse to identify changes that could have resulted in better outcomes. This station required discussion because classification of nursing actions into each category is open to interpretation. Sometimes, an organization's "facility" is less important in a nurse's mind than a "fundamental" of the nursing unit. Then, there is the problem with medication times that are fixed. Rules are rigid; however, practically, a stool softener mandated to be given at a fixed time is a debatable priority. Pain medication or an antibiotic would be a priority to give on time. However, all medications are treated the same for standardization of process. The debate stimulated thinking.

FIGURE 7 Five

Marny's Four

Marny's four (see Figure 8) is a method that one of the preceptors at this medical center has used for years. This prioritization method includes (a) meeting the needs of the patient, which might include pain relief, activity, elimination, nutrition, and thirst; (b) meeting the needs of the nurse, which involves medication orders, dressing changes, patient education, and discharge discussion; (c) meeting the patient's desires, which might include room straightening, idle conversation, and a cup of tea; and (d) meeting the desires of the nurse, which usually include some "buffing and polishing" of patients and housekeeping.

FIGURE 8 Marny's Four.

This concept, conveyed by nursing professors, can be compared to the classic concept introduced many years ago by Maslow. Maslow (1968) discussed the importance of meeting an individual's basic needs before those "meta-needs" or higher level needs.

Christine's Cure

Christine's Cure (see Figure 9) is another strategy that a preceptor can use to share experience and intuitive knowledge with a new orientee by making thought processes explicit. This strategy, developed by another preceptor at this medical center, was developed as a mnemonic device to help prioritize and organize the care of patients.

FIGURE 9 Christine's Cure.

All needs of the patient are important, but being able to prioritize these needs efficiently is crucial in nursing to provide care for multiple patients. The needs are organized from most important to patients' well-being to those needs important for the patient. The first priorities are the patients' critical needs. Critical needs are cares related to potentially life-threatening issues. Examples of critical needs are respiratory distress, unresponsiveness, and sudden chest pain. The next priority would be urgent needs. These may be safety needs, pain control, or anything that could potentially cause harm or discomfort for the patient. Examples of these needs include patients with bed exit alarms, low blood sugars, or acute need for pain medication. The next needs to address would be routine responsibilities. Routine responsibilities are scheduled daily activities that the nurse is expected to complete during the shift. Routine responsibilities would include assessments, vital signs, classification, and scheduled medications. Finally, the nurse should address extras. These are comfort requests of the patient and may include providing a warm blanket, ordering a video from the patient library, or offering hair care. All patients' cares or needs may be matched with one of these C-U-R-E prioritization categories.

Preceptors can use this tool when working with the orientee. The preceptor can ask the orientee to determine the prioritization of responsibilities of the assignments. For example, at 10:00, the preceptor and orientee answer a call light and find a patient is having chest pain, a scheduled antibiotic is due, and another patient wants fresh ice water. The preceptor may ask the orientee which need should be handled first. Using the tool, it is clear that the chest pain should be addressed first, followed by the routine duty of medication administration, and then filling the patient's ice water. If two responsibilities were of the same importance, then the activity taking the least amount of time to accomplish should be completed first. This allows the nurse to see both patients in a more efficient and timely manner. All needs and cares can be placed in a category and thus prioritized, making this tool adaptable to all situations.

THE OUTCOME

Preceptors who attended the forum engaged in conversation. Many had not specified or spoken openly on how they actually prioritized, but the suggestions offered in the posters helped them identify effective ways to focus and direct action. The preceptors took notes and brought ideas back to the work unit to use with new orientees. The forum posters were then placed on the preceptor Web site and highlighted in the online preceptor newsletter. Preceptors use the strategies plus some of their own. Preceptors were asked to talk about prioritization strategies that each orientee could identify using. When this conversation occurred, some orientees verbalized using the strategies suggested. Preceptors were encouraged to continue to track perceptions of prioritizing as each new nurse gained experience and to mentor novice nurses in this skill.

SUMMARY

The Medical Specialty Preceptor Council provides a forum for discussion of ideas to guide preceptors. The Council has tried to integrate theory, research, and practical ideas. The preceptor forum is a good example of such an activity. The Council will continue to check with new orientees to see if indeed they have been given direction in prioritization and will again solicit ideas from preceptors. The only reservation regarding this program is that nurses were drawing ideas from their years of experience, and often, the original sources had been lost. An idea remembered from nursing school is sometimes difficult to track down. A tremendous pool of common wisdom melds many impressions without precision. The authors hope that they have given credit where credit is due. If not, it has been in error, not intent.

REFERENCES