https://www.infirmiere-canadienne.com/blogs/ic-contenu/2024/04/29/timpir-doutil-dintervention-initial
Improves critical thought and clinical decision-making when faced with abnormal findings
By Jason Cohen
April 29, 2024
istockphoto.com/FatCamera
The TIMPIR acronym provides nursing students with a simple approach in their initial management of abnormal findings. Acronyms help ensure that all recognized factors are included in the data for analysis, and they assist with the prioritization of patient needs.
Takeaway messages
- The information overload associated with the clinical setting often inhibits nursing students in their ability to engage in clinical decision-making.
- The acronym “TIMPIR” (trend, identifiable cause, medications, prescriber & primary nurse, interventions and response) may assist nursing students in their initial management of abnormal patient findings.
- Informal observation of multiple clinical cohorts over the years suggests the possibility that the TIMPIR acronym helps student nurses focus on what they need to know and how to take appropriate next steps within moments of recognizing an abnormal patient finding.
The stress and anxiety that nursing students experience in the clinical setting can inhibit their ability to engage in critical thought (Aloufi, Jarden, Gerdtz, & Kapp, 2021; Marques da Rocha et al., 2023). In students who are within their first or second clinical practicum, I have often observed a kind of frigidity in thought and action when faced with new or unexpected assessment findings.
In 2009, I developed the TIMPIR acronym (see Figure below) as a tool for the mobilization of nursing students in their initial management of abnormal patient findings. The intention behind the use of the TIMPIR acronym is to direct initial data gathering and analysis and interprofessional collaboration in response to the identification of any abnormal patient data. Use of the TIMPIR acronym is also helpful in gathering data essential to the use of more comprehensive clinical decision-making tools or frameworks.
Figure: The TIMPIR acronym
Stress among nursing students in the clinical setting
It is common for nursing students to experience stress in clinical practice, and this stress impedes their learning and performance (Aloufi et al., 2021). Anxious individuals exhibit poorer cognitive functioning inasmuch as they tend to utilize lower levels of rationality and intuition when making decisions (Marques da Rocha et al., 2023). Anxiety compromises the ability to use effort-based strategies as the individual has diverted much of their mental energy toward anxiety-influenced processes, such as worry (Marques da Rocha et al., 2023).
Therefore, although it is ideal for nursing students to apply a decision-making framework within their clinical practice, stress and anxiety may inhibit accessing the complex cognitive functioning associated with the use of such frameworks.
A simple approach in the initial management of abnormal findings
The Safe Care Framework is an example of a comprehensive clinical decision-making tool that can help nursing students predict and manage changes in their patients’ conditions (Hundial, 2020). The framework includes 26 guiding questions, the use of concept mapping to illustrate relationships between the data gathered in answering the questions and the use of a priority-setting tool (Hundial, 2020).
The issue, as discussed above, is that such a framework might be too mentally burdensome for the stressed or anxious student in the initial stages of responding to an abnormal patient assessment finding. Novice learners require concrete rules and instruction, step-by-step directions, and help in organizing their knowledge, prioritizing information, and discriminating the features of situations (Persky & Robinson, 2017). Although the Safe Care Framework may provide the experienced student with many of these requirements, the sheer number of items that the novice learner would be expected to consider in this framework might constitute a form of information overload, and this would diminish their initial decision-making ability (Ledzińska & Postek, 2017).
The TIMPIR acronym provides nursing students with a simple approach in their initial management of abnormal findings. Acronyms help ensure that all recognized factors are included in the data for analysis, and they assist with the prioritization of patient needs (Lasater, 2011; Watkins, 2020). Acronyms are useful in acute care as they improve resilience to interruptions in the completion of a task or thought process (Radović & Manzey, 2019).
Finally, an acronym helps ensure that the steps of a task or thought process are completed in the correct order (Radović & Manzey, 2019). Students will build upon their initial, TIMPIR-guided thoughts and actions when they have the mental resources to process the patient’s case more deeply, utilizing a clinical decision-making tool such as the Safe Care Framework. The case study that follows demonstrates how the TIMPIR acronym can be utilized by nursing students.
Case study
Context
Pam is a nursing student in her first surgical practicum. On her second day, she is assigned a patient who had total proctocolectomy surgery six days ago. Highlights of the morning handover report for this patient are as follows: The nasogastric tube was removed a few hours ago, and a clear fluid to regular texture diet was ordered at that time; hemoglobin (hgb) was 79 g/L as at 10 a.m. yesterday, and the resident surgeon’s notes from yesterday indicate that discharge is “pending tolerance of a regular diet and an active stoma.” All of Pam’s initial assessment findings are within the normal parameters for a healthy adult, except for the following: fatigue and light-headedness; blood pressure (BP) 105/60 mmHg; blood glucose (B/G) reading of 3.8 mmol/L; moderate amount of nausea; diminished bowel sounds, all quadrants; no gas or stool present in the stoma appliance; and small amounts of concentrated urine output.
Pam knows that a clinical decision-making tool such as the Safe Care Framework can help her anticipate and address the needs of her patient. But she is feeling incredibly overwhelmed and does not know where to begin. Her instructor asks that she take a moment and apply the TIMPIR acronym to each abnormal finding.
Starting with TIMPIR
Pam appreciates the TIMPIR acronym because it is simple and directive, allowing her to initiate thought, action and interdisciplinary collaboration within moments of recognition of the abnormal findings.
Answering the Questions related to TIMPIR (see below) by way of using the Resources related to TIMPIR (see below), Pam generates a TIMPIR acronym response for each abnormal finding (see the Sample TIMPIR responses below). Writing a TIMPIR response for every abnormal finding may seem redundant for the seasoned nurse, as abnormal findings are often interrelated, but intuitively recognizing these relationships requires experience that the student does not often have (Persky & Robinson, 2017).
Deducing these relationships using a full-fledged clinical decision-making framework and rational thought processes may require mental resources that the overwhelmed student is unable to devote to the task at that moment (Ledzińska & Postek, 2017). The redundancy of the TIMPIR approach allows the student to consider each finding in a step-by-step manner, ultimately revealing any existing relationships between findings.
The TIMPIR acronym has enabled Pam to produce a concise list of abnormal patient findings, and potential causes for each, and has also prompted Pam to consider what she should do next and whom she should collaborate with in addressing each finding. Using her TIMPIR responses, Pam is able to quickly communicate to her instructor a list of current abnormal patient findings, her own thoughts around causation and potential interventions for each, and the extent of current involvement of members of the interdisciplinary team.
Questions related to TIMPIR
Trend
- When did this start?
- What is the usual baseline?
- Is the trajectory upwards or downwards?
Identifiable cause
- Is there a relevant event that preceded this finding?
- Is there a relevant primary or secondary diagnosis?
Medications
- Are there medications prescribed that could be contributing positively or negatively to this issue?
- Are there medications that need to be prescibed to manage this issue?
Prescriber & primary nurse
- Is the prescriber aware of this issue?
- Is the primary nurse aware of this issue?
Intervention
- What nursing interventions are appropriate in managing this issue?
- What potential or actual interventions of the interdisciplinary team are relevant to this issue?
- Who needs to be informed about this finding?
Response
- What impact have the interventions of the interdisciplinary team had on the issue?
Resources related to TIMPIR
- Patient assessment and interview
- Flowsheets
- Patient history
- Medication administration record
- Lab and diagnostic reports
- Interdisciplinary progress notes
Sample TIMPIR responses
Finding: Hgb 79 g/L
T: Hgb 67 g/L postoperative day (POD) 1 and trending upwards since then.
I: Blood loss in surgery & poor oral (PO) intake.
M: Prescribed anticoagulants may exacerbate bleeding.
P: Prescriber noted hgb of 71 g/L 4 days ago. Primary nurse is aware of the latest value per a.m. report.
I: Contact prescriber for potential transfusion
R: Not applicable at this point. (N/A)
Finding: B/G of 3.8 mmol/L
T: New finding this a.m. Has been greater than 4 mmol/L at this time on previous days.
I: History of type 2 diabetes and poor PO intake.
M: Prescribed oral antidiabetics may worsen the issue.
P: Prescriber is not aware of today’s finding. Primary nurse is not aware of today’s finding.
I: Inform primary nurse, initiate the hypoglycemic protocol, initiate PO intake as per prescriber orders. Monitor and report the issue to the prescriber as needed.
R: N/A
Finding: Fatigue and light-headedness
T: Ongoing since POD1 and worsening daily since then.
I: Blood loss, dehydration, low B/G.
M: Prescribed opioids and oral anti-diabetics may worsen the issue.
P: Prescriber noted mild fatigue 4 days ago. Primary nurse is not aware of today’s finding.
I: Inform primary nurse and contact prescriber for intravenous (IV) fluids and potential blood transfusion. (See interventions for the low B/G issue too).
R: N/A
Finding: BP 105/60 mmHg
T: Low BP since POD1 and trending downward since then.
I: Dehydration and blood loss.
M: Prescribed opioids might lower BP.
P: Prescriber noted BP of 112/68 4 days ago. Primary nurse is not aware of today’s result.
I: Inform primary nurse and contact prescriber for IV fluids and potential blood transfusion. Initiate PO intake as per prescriber orders.
R: N/A
Finding: Mild nausea
T: Intermittent since POD1.
I: Decreased bowel motility (paralytic ileus).
M: Opioids (prescribed) may worsen the issue. Anti-emetics (prescribed) may alleviate the issue.
P: Prescriber aware of the issue as noted 4 days ago. Primary nurse is not aware of today’s finding.
I: Inform primary nurse, offer anti-emetics, encourage mobility when appropriate.
R: N/A
Finding: Diminished bowel sounds
T: Ongoing since POD1 but is improving.
I: Surgery and decreased mobility.
M: Opioids (prescribed) may worsen the issue.
P: Prescriber aware of the issue as noted 4 days ago. Primary nurse is not aware of today’s finding.
I: Inform primary nurse, encourage PO intake and mobility when appropriate.
R: N/A
Finding: No output in stoma appliance
T: Ongoing since POD1.
I: Surgery and decreased mobility.
M: Opioids (prescribed) may worsen the issue.
P: Prescriber aware of the issue as noted 4 days ago. Primary nurse is not aware of today’s finding.
I: Inform primary nurse, encourage PO intake and mobility when appropriate.
R: N/A
Finding: Concentrated urine output
T: This is a new issue as of today.
I: Dehydration and low hgb (low blood volume).
M: Opioids (prescribed) may worsen the issue by lowering BP.
P: Prescriber and primary nurse are not aware of today’s finding.
I: Inform primary nurse and contact prescriber for IV fluids and a potential blood transfusion.
R: N/A
Progressing from TIMPIR to a clinical decision-making framework
Once a response to the abnormal patient findings has been initiated by Pam, her primary nurse and relevant members of the interdisciplinary team, Pam can devote the time and mental resources needed to explore the patient’s case more deeply through the use of a comprehensive clinical decision-making tool such as the Safe Care Framework. Data gathered through the use of the TIMPIR acronym — such as patient history, diagnoses, lab values, diagnostic results and medications — can be used to begin answering the guiding questions and developing the concept map associated with the Safe Care Framework.
TIMPIR and the nursing process
Informal observation of multiple student cohorts over the years suggests the possibility that the TIMPIR acronym helps in bringing the student nurse’s focus to patient baselines and related trends, may be quicker than the nursing process to implement, and may be more expedient than the nursing process in “creating connections” between data.
Informal feedback from clinical nursing instructors over the years suggests the possibility that the TIMPIR acronym is useful in bringing the student’s attention to data trends and the level of awareness of the most responsible nurse and the most responsible prescriber.
Therefore, a preliminary impression, based on years of informal observations and unsolicited feedback, is that while the nursing process may be relatively more useful as a medium-to-long-term planning tool, the TIMPIR acronym may be more useful in the immediate management of abnormal patient findings.
Implications for further research
Further research around the TIMPIR acronym could focus on the following areas:
- TIMPIR and the efficacy of student responses to abnormal patient findings
- Differential use and efficacy of TIMPIR and the nursing process
I would like to acknowledge the support and mentorship of the faculty of graduate nursing studies at Athabasca University.
References
Aloufi, M. A., Jarden, R. J., Gerdtz, M. F., & Kapp, S. (2021). Reducing stress, anxiety and depression in undergraduate nursing students: Systematic review. Nurse Education Today, 102, 104877.
Hundial, H. (2020). The Safe Care Framework™: A practical tool for critical thinking. Nurse Education in Practice, 48, 102852. doi:10.1016/j.nepr.2020.102852
Lasater, K. (2011). Clinical judgement: The last frontier for evaluation. Nurse Education in Practice, 11(2), 86–92. Doi: 0.1016/j.nepr.2010.11.013
Ledzińska, M., & Postek, S. (2017). From metaphorical information overflow and overload to real stress: Theoretical background, empirical findings, and applications. European Management Journal, 35(6), 785–793. doi :10.1016/j.emj.2017.07.002
Marques da Rocha, M. C., Malloy-Diniz, L. F., Romano-Silva, M. A., Joaquim, R. M., Olivieira Serpa, A. L. de, … & Marques de Miranda, D. (2023). Decision-making styles during stressful scenarios: The role of anxiety in COVID-19 pandemic. Frontiers in Psychiatry, 14, 1105662. doi:10.3389/fpsyt.2023.1105662
Persky, A. M., & Robinson, J. D. (2017). Moving from novice to expertise and its implications for instruction. American Journal of Pharmaceutical Education, 81(9), 72–80. doi:10.5688/ajpe6065
Radović, T., & Manzey, D. (2019). The impact of a mnemonic acronym on learning and performing a procedural task and its resilience toward interruptions. Frontiers in Psychology, 10, 2522. doi:10.3389/fpsyg.2019.02522
Watkins, S. (2020). Effective decision-making: Applying the theories to nursing practice. British Journal of Nursing, 29(2), 98–101. doi:10.12968/bjon.2020.29.2.98
Jason Cohen, RN, MN, is a nursing instructor at Vancouver Community College.
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