ICU nurses have a lot on their hands, and time management is an important skill to master when working the job. In this episode, host Jenny Finnell invites Shakira Thomas, the ICU Nurse Mentor, to share her experience and how she curated that into an effective system that works for her. From level one trauma center, cardiac surgery, stroke, COVID patients, med-surg, and ICU travel nursing, just to name a few, there’s no doubt that Shakira has had her run in the trenches. The biggest takeaway when it came to managing time? It’s all about organization, finding a system, and being confident. Get practical tips on how to make your job as an ICU nurse smoother by tuning in.
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How To Manage Your Time As An ICU Nurse with ICU RN Shakira
Welcome, everyone. In this episode, we are going to be talking about time management in the ICU. We have a very special guest, Shakira, who has been a nurse for many years, some of which were spent in the ICU. She has an extensive background that I will briefly cover with you. Level I Trauma Center, it looks like she has done trauma, post-cardiac surgery, stroke, STEMIs, CABGs, COVID patients, DKA, ARDS, and she has also dabbled in ICU travel nursing. She has been a preceptor in ICU for a number of years now. She is very well versed in helping new ICU nurses, whether they are new grads or just new to the ICU, be successful in ICU nursing. Welcome.
Thank you so much, Jenny, for having me. I am so happy to be here.
I would love for you to share why you are passionate about mentoring ICU nurses. How did this start for you?
I, myself, had a difficult transition as I worked in med-surg first, and then I transitioned over to ICU. It was a whole other world for me, and I did not feel confident there. I wished that I had more mentoring and more support. Even as a nursing student in critical care rotation, everything was so scary back then of feeling very overwhelmed. That is why I am offering mentoring services to nursing students and nurses who want to transition to ICU. I am helping with their confidence.
This is interesting to me because we have a lot of people who are pursuing CRNA who feel down the dumps about starting the med-surg. I always say, “You are gaining skills by working in med-surg.” They are vastly different than ICU, but you are still bringing something to the table. Could you speak about it? How did your med-surg help you transition to the ICU role?
I would say the most thing that med-surg helped me with was time management because you have six patients sometimes, depending on what state you are in. You get this flow down, these tests down, and you get your flow of being a nurse in how you should do things throughout your twelve-hour shift.
We are talking about time management, so that is perfect. When you made the transition into the ICU with time management being your strong point, how did you find yourself using those skills to help you in the ICU from the get-go?
I had already established checklists and doing things like bedside reports, which saves so much time in ICU. One of the most efficient ways to save time and have good time management in ICU is giving bedside reports. What I mean by that is you get to lay eyes on your patients, so you are already doing your assessment before you start your head-to-toe assessment. That is just one of the things.
Another thing is you get to clarify things with the off-going nurse rather than looking things up later, which would take a lot of time from you. That is one of my favorite things to do. You get to complete your skin check with that nurse. You are already completing your integumentary system part of the assessment.
You do not have to go back and do that again if both of you are already at the bedside, rather than standing outside the nurse station and getting a report that you have to go back and clarify things. Another example is when you are writing down the bed settings, just look over there when you are at the bedside and see if it is where they say it is. If it is not, just clarify like, “Did something happen overnight? Why is the oxygen or the FiO2 higher?”
You go ahead and figure that out and get your day started, doing things like completing your drip handoff at the bedside. That is going to save you a lot of time because you want to verify your weight and everything, so there is no confusion or no medication errors later. It is little things like that, even updating your whiteboard. Things your manager will come by when you are busy and they will say, “Did you do this?”
Do that at the bedside, get it out the way. You do not have to worry about it later. You do not have to worry about people coming up to you later and doing it. Those are some little things. My report sheet coming from med-surg, I knew I had to create some type of organization to succeed in the ICU. I have these boxes on my report sheet, neuro, cardiac, and respiratory. I am keeping it organized.Speaking out loud to your peers every day helps boost your confidence with speaking in ICU rounds. Click To Tweet
At the bottom of my report sheet, I have all the tests that I have to complete during my twelve-hour shift and check those off as the day goes so you are not getting behind. You know what time it should be done. I am not thinking about, “Did I do it?” I am not staying late charting. It is little things like those that I gathered from med-surg to ICU.
Did you make this report sheet yourself?
Absolutely. I offer it to the nurses and students that I mentor.
Orders were one of those touchy points for us, especially new orders that came in for the day shift that got put in overnight. One thing I remember doing way back when was, I remember that it was important to clarify my handoff. That is what is expected coming up in your shift.
That was always a courtesy thing like, “Be on the lookout for this. They put these orders in at 2:00 AM or whenever they did their nighttime rounds. It is not on my shift. It is on your shift.” You get flooded with orders during the day and it is easy to lose track of what is coming up. I love that organization piece and having a checkbox of, “I have done this.”
I am definitely a list person. If you are a list person, that is going to be good for you.
You mentioned checking off and checklists, but do you group your tasks together that save you time that you would be willing to talk about?
I love clustering my care. For example, if you are in there at 8:00 AM, you can give the 9:00 AM minutes at 8:00 AM and then you can go ahead and start getting ready for rounds, which you know are going to be at 9:15 AM. Clustering care at 8:00 AM. When you are in there, reposition, do your oral care, check your skin under the restraints, and document. You can document your assessment while you are at the bedside. You can even print your strips from the bedside. Some facilities allow that. You can do all of that while you are in the room, let’s say, between 8:00 AM and 8:15 AM. You can do all of that and then move on to the next phase of the day, which will be rounds.
Rounds, I remember for me at least, especially when I was new were intimidating. As I progressed, it did not intimidate me, but in the beginning, they were really intimidating. I remember always feeling shy to speak up. I am like, “Did I say something stupid?” How did you find your voice and how did you find your confidence piece as a new ICU nurse doing rounds with pulmonary fellows?
Rounds are a good way to practice your public speaking because some people who are ICU nurses, they are going to move on to CRNA School. Picture you as an ICU nurse, speaking and leading the rounds and having good practice with talking about the patient care. You are talking about it to the physician, the RT, the social worker, and everybody involved. Those skills are going to carry over.
For example, when you are in the OR and the physician asks you a question and you need to explain to everybody what is going on, it is a mindset thing that I love to prepare for. I have a rounding script and that is what gets me prepared for it like, “This is what I am going to say during rounds. This is what is pertinent to the plan of care.”
If I needed to, back in the day, I would practice it. I will say, “This is this. This is what is important.” For me, it is another checklist type of thing that got me prepared for it and then consistency. Doing it every day, and speaking out loud to my peers every day helps with my confidence. It helps with my confidence in speaking in ICU.
Sometimes you do it so much that you forget. At least, I do. I do not know how I do it. I know for me, and as I teach my students, slowing down and teaching others allows you to think about what you do and what your strategy is. When you’re giving a report, for example, whether you’re getting a handoff to the ICU nurse that you’re dropping off after the OR, talking to the surgeon or attending during the actual case…you have to be able to find your voice and not be afraid of messing up or saying something silly. What makes it easier is to follow a system. Head-to-toe assessment systems, cardiac, respiratory, hemodynamics, “Is there a problem in any of these major areas? If so, what is it?”
Think of some ideas. Do not just present the problem like, “There is a problem.” Take another step further and say, “Here is a problem. These are my thoughts around it. These are my thoughts of how we can fix it, what they need, what we can do.” You’re not going to have all the answers, but if you challenge yourself to think like that, I promise you, over time, you will start to pick up on it because then they will educate you on those pieces and you will learn. Repetition is key because the more you do it, the better it is going to seem, the less intimidating it is going to seem. A lot of this is giving yourself that grace.
You are new to this, so you do not always have the answers right away or you do not know how to speak in rounds right away. Consistency is going to get there. Practice makes perfect. You will get it.
Do you talk to your students that you precept? Do you ever say, “If you are ever nervous, just come speak with me first?” As a new ICU nurse, you could present what you want to present on rounds to your preceptor.
That is a good idea. That way, you don’t get nervous.
I was talking with one of my mentees and she was like, “I do not feel confident with communicating and reporting. Can we practice?” “Absolutely, we can practice.” Doing that helps you clear up things you do not understand in each system.
I am sure they all wish they had preceptors like you. I get it. Some people tell me these horror stories where they are like, “Jenny, I do not have a good preceptor.” What is awful to me is some of these health systems seem to take on the role of orienting a new ICU nurse with one person. That is their designated person, but if that person is not suitable for that role, it can leave them a terrible experience. I have had nurses fail. They do not even pass their residency program and are forced to look for another ICU job. Some of this, I truly believe, is bullying.
The person I am thinking about, I talked to her a lot. I was like, “You are going to be okay. You are going to do this. You are doing a great job.” It seemed unfair, more power to her. She went and got another job. She is doing great. She is rocking it. They love her. She is happier. If I am speaking to you and you are like, “I am struggling. I do not have a good preceptor. I have no one to turn to.” Sometimes it is okay to say, “Maybe it is time to look for something else.”
I am so glad you said that because I went over that with one of my clients who are in my program. She actually ended up losing her job from her ICU residency. They felt like she was not catching on fast enough. She was not getting along with her preceptor. That is something that happens. This is where we connected. We helped her gain her confidence. We even did a mock interview. She nailed her interview for her new ICU job. Now she is working in another SICU. She feels more supported there. It worked out for the better.
I love that we are bringing this up because it happens more than I think most people are willing to talk about. At least the student I worked with on this, it left her feeling shameful. It left her feeling like she was the problem, that she was not good enough, and that maybe she was not cut out for this. She almost gave up on her CNRA journey because of it.
I was like, “You are not giving up on your journey because of this. This is a stepping stone and you will be okay.” She was doing all the right things. It just goes to show the fact that she is thriving in a different ICU. They love her and she is the happiest she has ever been. It just goes to show that she was not the problem. It was the unit.Consistency is going to get you there. Practice makes perfect. Click To Tweet
It is okay. Not all jobs are created equal. Not all ICUs are created equal and it is funny…Even when I reflect on my time because people were like, “The ICU is terrible. It is toxic.” I am like, “That could just be your unit.” My ICU was toxic, but not from the people. It was toxic because of all the death and dying. That is the way I felt. I loved the people. We were speaking a bit before we started recording that I started working there as a nurse’s aide. I think I would have been way more intimidated if it was not for that, but I knew I had a family there. I knew I had people whose shoulders I could cry on.
I called them my mother hens. They were there to watch out for me. I knew I had support and that made my experience, night and day difference. I would never have made it. It was hard enough to deal with what we dealt with, all the death, suffering, uncertainty, being scared, and not knowing if you were doing enough to save the patient, etc. but the fact that I knew I had such an amazing staff to work with helped. I could have taken a position in the SICU and it was a much colder unit. Even a good friend of mine, we have been friends since we were in sophomore year in nursing school together; she worked in the SICU. I worked in the MICU in the same hospital, a much different experience with way less support.
It was a massive unit. She would say, “We do not have that relationship that you have in the MICU with your staff.” She did say, “I think your unit stinks because of what you tell me your experience is like.” The MICU is a really hard place to work. She was like, “Even though we have sick patients, what you deal with all the death and suffering and these chronic comorbidities. We at least have some people who make it out. I have seen them walk out of their ICU unit where you do not. You get them to nursing homes to return after getting a bed sore.” It was a different type of ICU experience, but she did not have the same support that I had.
The support is everything. Can I tell you about what happened to me as an ICU capstone student in nursing school? I was at the end. I was ready to graduate, ready to spread my wings, and something happened. We were in the med room and I was with my preceptor. This was the culture of this ICU. I was trying to find my way around the Omnicell. I was looking at the dose and everything. One of the ICU nurses started singing the Jeopardy song. That crushed me as a nursing student. It crushed my confidence because of things like that and the environment.
That is not funny.
Moving forward, I have never seen things like that being done to students or any other nurses. It depends on the culture and the people in the ICU, the support system you have. That is a little thing I remember from nursing school.
Those “little things” that happen throughout your day add up and over a period of time, you start to think negatively about yourself like, “I am just slow.” Even the students I precept in the OR will tell me like, “Jenny, I just feel messy. I feel like I will never be as good as you.” Every time I hear that, it crushes me because I am like, “Do not do that to yourself.” I also want to share the fact that I felt that way too. I still feel that way some days where I am like, “This is a hot mess express today.” I know there are some days when the room moves faster than I can physically. It is like, “I will do the best I can. I do not have ten hands and I will just do my best.”
My students feel very overwhelmed when they are in those types of rooms with me. I do not think they understand how overwhelmed even I am because I am so used to it. They do not know that beneath all of that, I am like, “This is crazy.” It is an unspoken thing that humans do not necessarily always speak what they feel. You, as a nursing student experiencing that, probably kept quiet. That nurse who did that to you probably had no idea that it affected you the way it did.
It was funny and all the other nurses were laughing, but I was like, “This is crushing me right now. I do not want to make it seem like I am scared.”
That is the stuff that I think really eats up people because it adds up. If it happens more than once, two or three different times on different occasions, let’s go back to the mindset piece. That is one of those things where you have to say, “That is them. I am me. I am okay. I will never stoop to that level. I am going to be the bigger person. I will never do that. Going forward, I am not going to be doing that to anyone I know. That is not an appropriate way to behave.” There were some people in my ICU that were notoriously not nice, not just with me, but to most people. They were disgruntled. They were the people who historically ate their young.
I had worked as a nurse’s aide. I worked as a nurse and I am like, “Here we go.” I did not take it personally. They said mean things that made me feel inadequate, but I remember thinking at the same time- and I do not know if this is the right thing to do, but I do it sometimes- if I have someone who is mean to me, I am like, “What friends do you have? I like my life. I like my friends. I will die for my friends. Can you say that about yourself?”
I am okay with that. I am okay that you were like that because you are not me. I choose not to let that affect who I am because I know I like myself and I equally like others. I will never disrespect others. “I just brought it up.” “That is you. This is me. Sticks and stones may break my bones, but words will never hurt me.”
I have to adapt to the mindset that whatever you say can never hurt me. “That does not feel like anything.” You are the one putting feelings and emotions towards those words. On the opposite, you can shut it off. You could say nothing to me because who are you to me in my world outside of here? Nothing. I have my friends and family who care about me. That is all I need.
“After these twelve hours of me doing the best that I can, I am going back to my happy family, my happy daughter, and that is it.”
You are going to have coworkers who do love you, so focus on that. Focus on your tribes that you work with and the people that are not your tribe. Just be courteous, respectful, and let it go.
That is the main thing. Respect each other. That is all I ask.
Thank you, Shakira. This episode has already been so amazing.
I am so excited. Thank you.
Let’s see what else we are going to talk about. I would love to talk about this because I am actually surprised to hear that this happened in 2017. Let’s talk about how you handle being tripled in ICU.
I am from St. Louis, Missouri. To give you a little background, I was working in Kansas City, Missouri, at this time when I was first tripled for the first time in the ICU. It was such a normal thing there that people would not stand up for themselves. The nurse-patient ratio was always three, sometimes even four, in the ICU. You would have a trauma patient, a stroke, some heart situations going on, and it was just not safe at all, but it was the norm. I did not like it at all, but I dealt with it even after expressing to the charge nurse and the management that it was not safe. Our union was just not strong enough at that point to break through, break free of that culture.
Everybody had three patients, sometimes even four. One of the huge issues is that Missouri is one of those states that is slower to promote patient safety. Fast forward to 2017, when we moved to California, the laws were much stricter. I would only have one patient or two patients in the ICU. I really felt like I could stand up for myself. If the charge nurse tried to give me a third patient, the answer was no. What gave me the confidence to do that was when I went to Sacramento with my union and we supported Senate Bill No. 227 for the patient’s safety. We were in the courtroom and we stood up for it.
That bill became a law. It will bill the hospital if situations like that happen again. The first time it happens, it will be $30,000. The second time, it will be $60,000. That is what changes it. It hits the hospital in the pocket, which changes and makes the change. From there on out, that is where I found my confidence to say, “No, I am not taking a third patient. We fought for this and it is saving myself, it is saving my license, and the patient’s safety, so no, I am not taking three patients.” That is the difference between being tripled and where you are in the country.
It is good to know that you can reach out to your union. You mentioned you could actually go to your union’s website and there is a form.
There is a form that you can fill out. It is a staffing objection form. You fill that out before you take the assignment. You take the assignment, but if something happens, that covers you. You can find that document on your unit somewhere. You just have to ask where it is. Try to connect with your union rep or go online and that is where you can find it. It saves you.All you can do is your best. Click To Tweet
When we had that COVID surge in 2020, our governor took the laws away for the patient’s safety because we all had three patients. The hospitals were filling up with COVID patients, so we all had to dig in and help. In California, we all have three ICU patients. It was scary when it was happening. I would fill out the staffing objection before my shift started. In case anything happens, that would save me and my license.
For those of you who are not part of a union, I know that that does exist as well, but you still need to try to reach out. Even we do it in our field in anesthesia, but contacting your lawmakers that are in your senate. Writing a letter goes a long way. Having people sign it and petition it is how you get their attention. They do not know. They are not in healthcare, but would they want their loved ones to be tripled on assignment when they are on their death door? Bring awareness to the problem by contacting your state representative. I know you can find out who your state representative is by a simple Google search.
Reach out to them, write them a basic, short letter, and have nurses sign a petition. Get everyone together on your unit, sign a petition, and let them know this is a problem. There is always something that could be done. It might not happen right away, but you are not going to be able to make the change happen if you do not first recognize that there is a problem and bring it to the state level. It needs to be national level, but it starts with the state first and then they build it from there.
The ratios have gone back to normal. That was a temporary thing, but still, you have those options to protect yourself. Another thing that helped me get through it was the mindset of it all, “I am here to do the best that I can in these twelve hours. We all have three patients. Just do the best you can while you are here and then you will be home, back to your family and everything.” The mindset that is like, “All you can do is your best,” helped me get through it.
The fact that you probably already came into that situation very well-organized, it sounds like the system, as far as having the report sheet and knowing how to be present during rounds and how to organize the flow of your day, is really important. I suggest that all of you make sure you are asking these questions to your preceptors, how do they organize their day, to get a gauge of how they do it. It is going to be the best way to start off. We talked about physician rounds, but let’s talk a little bit about teamwork in ICU because I know, for me, that was a huge part of time management. It is a lot of delegation, believe it or not. Let’s touch on that too.
To shed some light on teamwork, I wrote down some questions because some people do not think about EVS as being in our team. I wrote down some questions. “What would our ICU rooms look like if we did not have our awesome EVS staff to, first of all, prepare our rooms for us? How would our day go if the pharmacy did not prepare our drips on time?”
Pharmacy is a part of our team, EVS, the physicians, and the RTs. “What if the RTs were not able to calibrate our ventilators? What if the nurses were not there to be there for the patients?” Everybody is a part of the team. Always ask for help. Do not be afraid to ask for help. Ask your resource nurse or charge nurse if you feel like you might be behind.
Ask ahead of time, do not let things linger. That is going to keep everything on task. It is safer for the patients. Just go ahead. If you feel like, “I am going to be in here doing something for a while.” Go ahead and ask someone out at the nurse’s station if they can keep an eye or an ear out for your other critical patient. Listen out for the ventilators and the IB pumps because they could be labeled if they are running. It could be something that is vital to keeping them alive. Listen out for the bed alarms. Listen up from the cardiac monitors. Ask for help. That is the only thing that I would say about teamwork. Do not be afraid to ask.
I love how you mentioned seeking that out early. That is a huge concept. Even for CRNA School, when you are struggling, you have to be proactive with what you need. Do not wait until a problem happens to seek help. Anticipate the problem arising or brewing and then get help at that point. Once the problem actually occurs, once a mistake actually happens, it is hard to mediate it at that point.
I routinely remember, when I started in the ICU, it was weird going from being a nurse’s aide to being a nurse, and then asking the same nurse’s aides that I worked with as a nurse’s aide to do things for me. “Hi, there. Can you go do this and do that? Thank you.” It is necessary. There are so many moving parts to one day at work. It is not just nurses. It is not just nurse’s aides. It is the housekeeping, the pharmacy, the RT, the physicians, and the unit clerk.
You will find things you need and there is always someone there to be a resource and help you do your job efficiently, but you have to know when to speak up and ask for certain things and not be afraid to do that. You can always do it with a smile and some days, you are going to be needy. You say, “I owe you a coffee. I am calling and banging at your door every second, but that is what you are there for.” That is what they are there for. I think everyone understands you are going to have days where you are going to be more reliant on your next-door neighbor. Our ICU did not even have any doors. They have a much nicer unit now, but we just had curtains.
It was just a big unit with a curtain, but it allowed us to be close to one another. We had our computer parked outside the curtain and then the next nurse was a pane of glass away. There is not much separation in our ICU, but it allowed us to be very close. If I needed to give my full-blown attention to this one patient because they got unstable, I would use my neighbor and say, “Can you watch out for this patient? They have a problem. I need to be in this room.” They would be happy to do so because you do the same thing when the roles are reversed and they need your help. Do not be afraid to do that.
Sometimes you are like, “My pod partners are not the best,” but you will have to find it within you to say, “I know they are going to give me gruff. They are going to roll their eyes, but I am still going to ask anyway.” If they tell you no, that is when you march your butt to the charge nurse and let them know, “I needed help. I fell on my resources. They told me XYZ, so that you know. I want you to know that this is a problem, that we are not working together as a team.” Mediate that going forward. If they get disgruntled about that, that is their problem not yours. You are doing the right thing by addressing it because if they want to keep working in that unit, they need to figure out how to work with the team too.
I forgot to mention one thing you can do on most monitors. You can select one other patient view so that when you are in your one ICU room, you can see your other patient’s vital signs too. If you see that they went techie, you can just stick your head out and say, “Can you go check on them and make sure that they are okay because they were assigned to serve them before this?” That is another quick tip. If you see the blood pressure drop, just stick your head out and ask, “Can you go check on so-and-so?” If you see the O2 drop, ask somebody to go check on them. That is another good tip that you can use in the ICU.
Definitely make sure you are watching at all times and there is someone around when you have to step away from the bedside to go make a phone call. We did not have portable phones. We had to go to a desk with a phone that was tied to a station. That was stressful because sometimes you had to make these phone calls when your patient was unstable, so either you would delegate someone else to do the phone call for me or if someone was already there with me I would do it.
I remember the one time I actually had this happen to me. I was a brand new ICU nurse, not even in an ICU on my own for more than a week. It was the middle of the night. The patient I knew was having a stroke based on the symptoms. I had my other nurse from the bed right next to me, who was way more seasoned than I was and was like, “This is my suspicion. Please go into the room. I want to make sure she has a nurse by the bedside.” This patient was transferred off our service, but I am like, “Everyone go in that room, hands-on deck. I got a call for service because this is something that is really wrong.”
No sooner than that, then the whole Cushing’s triad happened. It ended up being a good thing, but it was one of those things where I was glad. I was like, “Get your butt in my room right now. There are problems. I need to figure out what to do. I need to call her actual medical team.” Even though, at that point, I am like, “It is a way more appropriate for our ICU team to be here right now.”
Make sure you are utilizing your coworkers. If you have a more seasoned nurse, have them look at your patient because I had never seen that before. I knew it was wrong, but I said, “Ashley, go in my room and do your neuro assessment because I want to see if you are thinking the same thing. I am thinking.” She is like, “This is bad.”
You stuck with your intuition. You knew something was wrong.
First, she was like, “It will be okay.” I was like, “No, I want you to go look at her.” Call on your seasoned staff to confirm your thinking.
That is totally okay. Even sometimes, you might have seasoned nurses come to ask you to help with technology, for example, like, “I do not know how to do this.” That is where teamwork comes in.
Shakira, let’s tell people where they can find you. You mentor new ICU nurses or not even new nurses, but nurses who are new to the ICU. I would love them to get in touch with you.
This has been an incredible episode. We are going to make sure to share the report sheet that you have as well. The overall takeaway is time management will come with time, but the organization is a big part of time management and getting a system like you mentioned; then repetition, consistency and feedback from others. That was liquid gold in this episode. Thank you so very much.Don’t be afraid to ask for help. Click To Tweet
You are welcome. Thanks for having me.
You will be coming back, I am sure, down the road.
Thank you. I would love it.
We will see you guys in the next episode. As always, I appreciate your loyalty for tuning in. If you would not mind leaving me a review, I appreciate you so very much. Thank you. Shakira, it was so nice to have you.
Thank you, Jenny.
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