Some thoughts on shift workload management.

I get a lot of questions from nurses who are struggling around issues of clinical workloads and time management. And its not just in critical care areas such as the emergency department, these days most clinical areas have become task rich, time poor environments that place many nurses under a great deal of stress.

Now, as a nurse with 31 years bedside experience as well as a regular meditation practice and interest in clinical management strategies to minimise these exact stressors, you might think I float through my shifts with a profound efficiency and a zen-like presence.

So. Totally. Wrong.

In reality, if you are working with me on a busy day you will see someone just as frazzled and entangled in interruptions and gridlocked-multitasking as any other nurse. So I don’t think there are any easy answers here.

However, I can offer some tips that you can try to integrate into your shift to make the whole thing just a little easier.

Just one thing:

Ask yourself: what is the next most important thing I need to do?

Try to keep the multi-tasking to a minimum. By this I mean when you are performing one clinical activity, try to give it your full attention right through until it is finished.

Avoid a continuous mental rehearsal and analysis of all the other things you should be doing. This distracts you from interacting fully with the task at hand (and potentially missing important opportunities to deeply engage with your patient or detect red-flags, or gut-feelings).

In my opinion, a nurse that provides quality care in anything they do is far superior to a nurse that just does everything.

Cluster your care:

If you performing an intervention with one patient, ask yourself if there is anything else you could do before you leave.
Do they need any meds? How is that IV going? Do the bed sides need to be up? Can they reach their call-bell? Do they need re-positioning?

Do a quick end-of-the-bed assessment. Is there any potential problems here? Airway. Breathing. Circulation. Mental status. Gut-feeling.
If you need to to a more thorough assessment, move in.

A really good habit to get into is before leaving each patient ask them 3 things:

  1. Is there anything else I can do for you?
  2. Do you have any pain?
  3. Do you have any questions right now?

Taking the opportunity to pro-actively address all the patients needs in a cluster can save you time and multiple trips in the long run.
Pain. Pan. Problems.

Maintain a situational awareness:

Even though you are attempting to practice vertically (concentrating on one task with your full attention) rather than horizontally (trying to juggle the whole shift around in your head simultaneously) , it is still important to maintain a situational awareness.

By situational awareness, I mean a wide-angle receptiveness or background monitoring to what is going on around you.

As you become more experienced this awareness becomes more developed and you really don’t realise you are doing it until suddenly something snatches your entire attention for no apparent reason. Perhaps it was a sound or a smell, or something you see out of the corner of your eye. Perhaps something more obtuse or subtle than that.

Whatever it is, your situational awareness will save your arse, and your patients lives on more than one occasion during your career.

As you mature as a nurse you will begin to acknowledge that the things that call out to you loudest are often not the most important. And the things that demand your attention the most are sometimes nothing more than dangerous distractions.

One way to develop the ability to run this background monitoring is to develop a regular mindfulness practice.

Throw the switch if need be:

If something else comes up, assess its importance. This may be something to do with the patient you are attending to now, or it may be something from far afield.

Ask yourself: Is it something that deserves pulling you away from what you are doing now?

If it is, throw the switch. Disengage from your current activity and focus on the new scenario with your full professional acumen.

Again, the reality of nursing is that we must often sacrifice doing some things or finishing some things during each shift. Other tasks will be attended to far later than should be.

Don’t be afraid to say no to all those interruptions that try to pull you in 10 different directions. No.

No. No. No. But say it nice.

Conversely, always be open to helping out a colleague if you are able.
And that brings me on to….

Ask for help:

Super important. If you are struggling with your workload you need to ask for help.
If you are not sure what is the most important thing you should be doing next…ask for help.
There is no shame in this.

If you’re juggling, you’re struggling.

You may notice you only have two hands and two feet[1]. It is generally assumed that nurses have more. But we don’t.

So (for the sake of our patients and our own health) it is incumbent upon us to monitor our individual workloads and at least try to enlist more resources when we are spread too thin.

This may involve asking for help from your colleagues, or talking to the most senior nurse on the shift, or even, in cases of chronic high workloads making an appointment to speak to your unit manager.

Remember, you are the boss of the clinical care you deliver to your paitents.
Your manager and senior staff are tools for you to use to improve that care delivery. Asking for help is not a weakness it is a strength.

Keep a must-do checklist:

It might be a notebook or simply a piece of paper that you carry in your pocket each shift.
Get into the habit of keeping a dedicated checklist of all the things that you feel must be accomplished during your shift.

In reality there will be fewer things on this list than you might think. Critical medication deliveries, important information that must be documented or conveyed, or perhaps patients that need to be monitored closely through the shift.

If you are getting distracted or drowning in tasks, pull out your must-do list and prioritise them against this.

If by the end of your shift you have not even been able to complete your must-do checklist, these are the things to hand over to the next shift.

Review the shift and then let it go:

It is important to take a few minutes to review the shift before you leave work. This is best done after you have left the demands of the clinical space.

Relax for a second and run through the day (or night) and see if there is anything you might have missed that needs to be followed up on.

If there were any critical incidents or things that have impacted on you it is useful to have an informal discussion with a trusted colleague at this time.

If there are any formal reports that must be completed related to issues from the shift try to get some time to attend to them before you go off duty (how many times do we end up staying back to finish off reports and paperwork?) Try to program this into your timeline.

It is important to see your physical movement from work to home as a time to make the mental transition back to the rest of your life.

Take a few moments as you walk to your car or ride your bike to re-align by silently soaking up the vast open beauty of that whole world outside the building you just left.
Yes you are a nurse. But you are so much more.

Your best shifts may be your most disheartening:

Despite all these tips it will often be difficult. Impossible actually.
We work in sometimes overwhelming, always dynamic clinical environments. Things are constantly in flux.

I wish I could tell you otherwise, but is inevitable that you will lie awake in bed some nights ruminating over your shift. Replaying all the things you didn’t complete. Beating yourself up for all the things you didn’t even start.

I can, however,  tell you this with absolute certainty. Over the course of your nursing career you will accomplish far more important things than the nagging, smattering of missed tasks you lay awake worrying about.

  1. I once worked with a nurse who only had one arm. She lost the other in a skydiving accident. She was brave and inspirational and should be writing this article. 

3 thoughts on “Some thoughts on shift workload management.

  1. This is a timely article for me to read- my clinical area is less acute- usually, can become more acute at a moment’s notice for varying reasons, and we operate independently of an on site MO after hours. They become an on call presence. When I shift coordinate I have to maintain an overall situational awareness, assist my staff and take care of walk ins. We’ve had some tough shifts lately with a wide mix of clinical situations and I work with a fellow nurse who does this prioritising very well. She sometimes gets a bit bummed she doesn’t finish things to her satisfaction, but she’s an excellent clinician that keeps people safe and well, and addresses the important issues. I will share this with her.
    Thanks again Ian, and kudos to the one armed nurse, what a champ!!


  2. Very interesting article, thank you Ian. I am in management, of only a small team, but my whole day is spent asking myself “what is the next most important thing to do?” Or “where is it best to spend my time?” Works for me! Jo


  3. Great article, Ian, and timely for me. I had one of those stressful shifts where I was juggling and struggling last night, and I ruminated longer than I should have, even though a colleague sent me off home at the end of it with “let it go…” playing in my head, as I apologised for all the things I was sure I hadn’t yet done…though in actuality, I think I got there by the end of the shift, with some help, and it was done, even though I was off very late.. the reminder to be mindful and to meditate as well as keeping a pocket list was very helpful. Thank you.


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