"Fired for NO Reason"

New grad here. Thank you, Ruby, for your post. I'll keep it in mind as I start my first job.

Everyone has a unique interpretation of Ruby's post. Here's mine: I don't think it's about new grad versus veteran, young versus old, or even about nursing. It's about Sal's lack of insight.

Sal will have the same problem wherever she goes, whether she's an accountant or a nurse or a teacher. She'll always have this problem in her relationships, too. It will always be someone else's fault. Until she takes responsibility for her behavior and her actions, until she sees that she is not the center of the universe, until she sees that she is a bit player on the world stage, she'll always believe that everyone else is the problem. Haven't we all worked with Sal somewhere? As one poster noted, you've got to open your mind to learn.

Now, if you don't mind, I've had my license for seven hours. I've got to go celebrate.

If you're task oriented you focus on the jobs that need to be done (do the obs, give the meds, wash the patient) but don't think about why these need to be done.

So, for example, I'll sometimes find stable stroke patients having neuro obs a week after admission (GCS unchanged since presentation), because nobody thought about why this patient needed neuro obs and if that's still necessary. Or a patient has been on BD obs so the non-critical thinking nurse doesn't (or doesn't consistently) put together a change in condition with increased monitoring.

Obviously this is a fairly basic example, and for the most part most of us employ at least some critical thinking in our day-to-day practice, and as our knowledge, expereince and awareness of all the factors that interact with our patient's condition increases, we think more intelligently about what needs to be checked, changed and followed up. As you say, erik, it doesn't seem extraordinatry. If you're doing it.

For those nurses who don't seem to be able to think critically, the concept is invisible. It's not a process of elimination, perhaps because the connections between BP and meds (or reasons why an APPT might have dropped) aren't there.

A lot of people use the expression "critical thinking" to mean any mental process. that makes it hard to pin down as a concept.

Nurses need to be able to assess a situation -- to put a bunch of observable facts together and understand how they all fit together -- identify problems -- and then go through a process of sound reasoning to develop a plan. Unfortunately, not everyone has those intellectual skills. Some people see a lab value and all they see is a number: they can't see a relationship between that number and the other facts of the situation. Some people may see a problem, but can't figure out what might be causing it ... or can't think through the possible interventions and choose a reasonable one. They only see the concrete thing in front of them and can only see it in isolation. Those people really don't have what it takes to be a nurse -- unless they can improve those skills.

With my first example - failing to check the BP before giving the antihypertensive is only a symptom of her bigger problem that exacerbated an existing issue. She should have been checking the BP regularly throughout the shift, as we already knew she had a potentially dangerouly low BP at 12:20. She didn't put together A (a drug with known antihypertensive sude effects), B (an already low BP) and C (a situation that warrants more frequent monitoring). She then compounded the error by not thinking "I'm giving an antihypertensive drug to this patient - what's her BP? Is she clinically stable? Should I assess her before giving this?"

In the neuro obs example, it's a combination of length of time and stability of observations. If a stroke patient had the same GCS for 24/24 I wouldn't cease the observations because there's still a danger of extension or of bleeding into an infarct, but at a week that's significantly reduced. You're doing the observations to pick up a deterioration in condition as early as possible, in order to investigate and - if possible - intervene. If the GCS suddenly drops then maybe they need more aggressive anticoagulation, or neurosurgical review, or inatropic support (if they're inadequately perfused and hypotensive)... You wouldn't necessarily know that if you don't work with stroke patients, but all the nurses on my ward ought to.

I hope that's made sense - it's been a long hot day without sleep and a busy night...

And I agree that the tasks need to be done. The difference is that the tasks should be a means to an end (like improved patient condition and outcomes, reduced pain, reduction in wound severity) rather than ends in themselves.

The problem with BSN programs is that they place a lot of emphasis on theory and very little on actual hands on experience besides the clinicals.