At the beginning of her shift on an orthopedic trauma unit, Laura, a registered nurse with 3 years of experience, identi

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At the beginning of her shift on an orthopedic trauma unit,
Laura, a registered nurse with 3 years of experience, identified
and prioritized several tasks that she needed to complete during
her shift, listing times for scheduled medications, three complex
dressing changes, helping a patient on postoperative day 1 to get
out of bed, and discharge teaching for her patient Mr. Davis, who
was going home after a long hospitalization for the treatment of a
severe compound fracture of his lower leg. Laura knew that there
was another patient in the emergency department waiting for
admission to the unit, but there were no empty beds; the only bed
that was going to be available was the one Mr. Davis now occupied.
Laura anticipated a busy shift.
In addition, Laura's patient Mr. Miller complained of pain in
his abdomen and asked for medication frequently. After assessing
each of her six patients, Laura collected the discharge papers for
Mr. Davis and started her teaching with him and his wife, who was
going to continue care of the large wound in Mr. Davis’ leg at
home. Mrs. Davis had numerous questions and what seemed to be a
routine discharge became more complicated when she asked Laura for
a home health referral so a nurse could help them manage Mr.
Davis’s wound at home. Soon, Mr. Miller rang his call light and
asked for pain medication; a nurse colleague stepped into the room
to tell Laura, “Your frequent flyer in Room 312 rang again.”
Several minutes later, the ED charge nurse called to ask when a bed
was going to be ready. The patient in the ED had been there since
10 p.m. the previous evening. Laura began to feel a bit of stress
but decided to reprioritize her day.
As she stood at the med cart and reviewed Mr. Miller’s pain med
use, she noted to her colleague, “He has got to be drug-seeking.
That is the only explanation.” She decided that she could forgo for
the time being getting a home health referral for Mr. Davis; she
understood that until he went home, she would not have to do the
long admission process for the new patient coming from the ED. When
Mr. Miller asked for pain medication a second time, Laura rolled
her eyes and continued to check the morning laboratory reports;
when Mrs. Davis came to the nurses’ station to ask about the
home health referral, Laura told her, “I called the social worker
to come up to see you, but she is busy and can’t get here until
midafternoon.” Mrs. Davis thanked Laura and walked away, at which
point Laura turned to a new nurse in orientation and told her, “And
that’s the time management skill they don’t teach you in nursing
school” and high-fived another colleague.