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LTCnurse11 3,226 Views

Joined: Jun 5, '12; Posts: 64 (19% Liked) ; Likes: 17

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  • May 27 '14

    Quote from CraigB-RN
    i don't read the "breed apart" as a derogatory comment. Every specialty area can say that. It takes a certain kind of person to thrive in the OC environment of a high acuity ICU, just like it takes a different kind of person to thrive in the ED, Ped, Onc and the like. Each has it's own thought process, Priorities etc.

    My own comment to the list. Repeat #3 constantly for the rest of your career.
    I am a special breed who can only keep track of two patients at one time.

  • May 27 '14

    Well said francoml. It is great advice. You ahve learned a lot and grown exponentially over the last year.

    10:58 am by VANurse2010
    I don't think ICU nurses are a breed of their own. It seems the people who think that are the ones who've never done anything but critical care.
    I think all nurses have their own niche where they fit the best. I think ALL nurses are a breed apart. Nursing has become very specialized over the years and each area has it's own set of skills required to survive.

    I think in each area of nursing the nurses are a bred of their own. ER nurses usually do not like critical care. Critical care nurses don't like the emergency department. Many med surg nurses would do anything to not float to ICU. L&D and OR Surgical nurses have their own thing going on and you just can't float anyone there to be helpful. NICU/PICU nurses are a breed unto themselves.

    I have spent a lifetime (with the exception of 6 months), 35 going on 36 years to be exact, in critical care/emergency department arena. I have NO floor nursing skill...NONE! It takes a special person to take care of all those patients coming and going all day long. The closest I came to "floor nursing" was a IMCU/step down unit. I love the geriatric population however I cannot stand the way they are cared for...or should I say the way they are not cared for....sigh.

    I have been a supervisor, administrator, instructor, a manager, a flight nurse, an ICU nurse and a ED nurse. Each had it's own set of challenges.

    Me personally....I do not have the floor nurse set of skills any more. I also avoid OB like the plague. I can resuscitate the mother or the child....leaving them combined terrifies me. It always has....the worst thing that came be heard at a hospital is CODE BLUE L&D. It always makes me a little sick to my stomach. I KNOW what to just makes me anxious. Always has. So much can go wrong! So much can happen..... I prefer to resuscitate something larger than the palm of my hand. Hats off to NICU!

    I agree that I think nurses in very specialized critical care areas are a little different that other nurses. They thrive in the critical environment. The anxiety, anticipation, and complexity is intoxicating. They can be aggressive and opinionated. They appear harsh and unbending...intolerant. They are passionate and protective. They don't mince their words.

    I'd rather triage a bus load of senior citizens with chest pain and care for an open chest with 13 drips and all the equiptment in the department in thier room than care for 8 patients on the floor. The thought of caring for that many patients fills me with anxiety. Sure I know how to code them...but care for them collectively? Shiver.

    Hats off to floor nurses.

  • Apr 13 '14

    My favorite was the mom who brought her 7 year old in the middle of the night for vomiting....once....36 hours ago!! Really??? Whatever happened to saltines, ginger ale and time? Works wonders. Then she freaked out when I had to start an IV and give fluids. She asked if he really needed the fluids, I said since he isn't holding anything down yes he did, then she said it was only once awhile ago...I nearly bit through my tongue on that one!

  • Apr 13 '14

    Quote from DebblesRN
    I think my favorite was the girl who came by ambulance (no lie) because she was 18 weeks pregnant and her breasts were leaking. The best part was that she had an entourage FOLLOW the ambulance to the hospital. You mean that one of them could not have brought her in since they obviously had a car?? EMS needs to be pulled from an EMERGENCY for colostrum leaking from your breasts??

    I also appreciate people who come to L&D and KNOW they are getting a vaginal exam but have not washed in at least a week. I will NEVER understand that.
    Regarding not washing, I'm with you, sister. I worked in L&D for years. I know that it's hard to be fresh as a daisy when you're pregnant. But for heaven's sake, if you know you're going to the doctor or the hospital (and it's not an emergent situation), then BATHE!!! I'll never forget the time I put a scheduled cesarean on the table and looked down only to see mud balls between her toes and, well, basically socks of red mud. I asked why her legs were so dirty. "I decided to go for a walk before I came in this morning." And you couldn't put on shoes? Or at least utilize a hose before getting in the car?? Who thinks bringing mud with you to the OR is a good idea? I've also encountered green slime when doing a preop abdominal clip on someone for a c-section. I expect some odor and discharge from pregnant va jay jays, but not from the lower abdomen.

    The dumbest complaint I ever heard (good lord, how does one choose that honor? there are so many!) is a patient who showed up in triage c/o "the baby is moving too much, it's annoying." And what, pray tell, would you like for ME to do about that?

    The worst one associated with an ambulance ride? 3 am triage arriving via ambulance from another county (of course, as to be expected, she was followed by at least 6 relatives who came by private car) with a c/o "yeast infection." I asked if she knew that she could buy monistat over the counter. "Yeah, but I'd have to pay for that." I woke the doctor with that nifty little report, and got an order: Discharge after 20 minutes of reassuring fetal monitor tracing, patient may buy monistat over the counter. He didn't even come out of the sleep room to see her, he said he was afraid he'd start yelling.

  • Apr 8 '14

    Quote from LTCnurse11
    The whole deal is that I know I'm interested in acute care and like the learning, but I'm not 100% the right time for me. I only was there 3 months and was burned out from nursing school and the EMT program right after. I really want to be sure I don't force myself into another mistake. I am feeling very upset about having been terminated and I think part of me wonders whether or not I'm cut out for it. I know I can do it. I just need more training or something. I also would like to have the option to further education by obtaining that benefit.
    This post says it all; it may have not been the right time for you.

    The thing about transitioning from LPN to RN is you have to go BACK to being a novice nurse ALL over AGAIN-the role expansion and the information from the new role and in a new setting can be a HUGE shock as well as a learning curve, at least it was for me; then add a new grad program that is transitioning, well, it was a miss for me, and I had a few (understatement here) components missing-I was simply NOT ready.

    I think I wanted someone who was in my position to mentor me desperately, but I forgot the key issue that helped me shape my previous nursing years-me. I was nervous, felt like a fish out of water and had very song attributes that if I had my heckles down and a strong base before jumping into where I was (PICU), I would still be there...although That doesn't mean I can't succeed there, just at a different time and where I can see myself being there; it anywhere else in acute care; it is still possible and VERY early in my practice.

    I currently work in LTC as a nursing supervisor-this job helped me hone the skills that I think I was lacking a year ago; I hope to be moving back to sub-acute/post-acute/step-down as a base FIRST, keep myself educated, and try again.

    I suggest you try again; learn this year FIRST; it's rough! Get to know the "newness" of being an RN; it's even (slightly) different; the approach to pts; it's an evolved approach that comes with the territory.

    Keep looking for other positions, as well as higher acuity patients at faculties; even if it's a LTACH perhaps.

    Trust me, it gets better; just that your path to you goal has become more interesting.

    Sending positive vibes on your success-you WILL get there!

  • Jan 10 '13

    Interestingly, the term critical thinking, is open to numerous interpretations. Some people think other people aren't thinking critically when they are, they just aren't willing to look at other issues at play, and vice versa. It's a term that has been tossed around so much, it's competely open for interpretation.

    And while EBP is good in many ways, it too has it's limitations. This is why I say I would be thrilled just to have people using logical processing, apart from emotional influences, more than anything else. I could give a zillion example, and I think it would lead to a thread war, so, I will hold off on some great examples.

    Also, some people get nervous, and even though they can think logically and intelligently, they haven't had the opportunity and training to think in drilled situations. This is part of why soldiers are drilled over and over again; so they do certain thinking automatically, rather than adding emotion or other issues into the process. This can be good or bad; but when it comes to protecting yourself or your buddies, some things require immediate action without a lot of diliberation. But people can practice thinking things through in stressful situations if they have the right support and guidance. Often, they don't have the right support and guidance, only people that are too quick to judge them as buffoons or clueless or whatever. And yes, then there are those people that are given a couple a dozen chances, and they still can't get important things right. For most nurses, IMHO, it has to do with their level of confidence and the people that are coaching, teaching, precepting, and supporting them, or not. And I am not for babying students or new grads either. I just don't see the need to add to their already incredible levels of new nurse stress. Experienced nurses often forget what being new feels like. But there is a time for trained responses, and a time to think and deliberate logically, and there is also a time to look at things from a totally different perspective.

    Finally, there are many different types of thinking for various situations. Some people are stronger in certain areas that others. This is one reason why teamwork can be a beautiful thing. Sadly, the lack of it can be an utter nightmare.

  • Jan 10 '13

    I would just like to say that to learn critical thinking, one must have the tools they need to do their job.
    Absolutely. I would say you are lucky that you have a clinical educator to assist you through your orientation because there are nurses our there who do not have clinical educators at all (smaller hospitals) but it sounds as if yours did not help you at all.

    You really shouldn't be held totally responsible for not asking the right questions either. You don't know what you don't know. As preceptors, we should be doing a lot of question and answer sessions with our preceptees. "What if" scenarios, What went well, what didn't? What would you do better next time? What has been your experience with this type of patient? What do you know about disease x? How can I help you learn? Help me to understand why you chose those interventions?

    I could go on and on with critical thinking questions that preceptors should be asking their preceptees to get a better understanding of their thinking and to help them to solve problems with them and not for them. Show them CURE steps or have them watch me do a procedure or assessment and ask them purposeful questions about it when we are done. Not merely saying - do you understand - as that gives you minimal feedback into their thinking.

    OP: I am so glad you did not give up, but rather see this as a learning opportunity for yourself on how to properly precept in the future.

  • Jan 10 '13

    Quote from LTCnurse11
    I critically think everyday and I do well with it. I just need to hear if others have been told "they got it or they don't". To me that's over simplified thinking.

    Hi LTC nurse11.

    What is oversimplified thinking, if someone is said to "have it or not"?

    Yea pretty much people oversimplify judging if others have it or not, especially in light of subjective, incomplete, or only partially or clearly set, objective definitions.

    The problem, IMHO, in nursing is that there are people coming into things trying to validate themselves or others, or they seek to invalidate others--too often to make themselve feel one-up or superior, or to get some social edge; thus they set forth with judgmental or subjective analyses of things.

    They may use terminology such as "critical thinking" in order to rationalize their subjective evaluations of people or situatuions. I have, from day one, had a huge problem with this in nursing. There is too much ego nonsense in healthcare, including nursing and medicine. It's silly and counterproductive. And in general, there is way too much judgmentalism of other nurses, their practices and characters, or even "fit," that causes disunity in the field. People are too quick to throw titles on each other.

    I like this business definition of critical thinking:

    "Objective examination of assumptions (adopted rules of thumb) underlying current beliefs to assess their correctness and legitimacy, and thus to validate or invalidate the beliefs."

    You can think critically about whether a long-held treatment approach is the correct path to use in a particular situation.

    I had a kid once that had tracheal edema from an unidentified, presumbed infectious agent. The child had received a good number of IV decadron doses, and was on broad spectrum IV antibiotics. Of course, sensibly, he was explored and intubated in the OR, and this I understood without question. He was on IV sedation, but was on the light side, and was continuing to receive the aforementioned medications around the clock. He awoke and was scared and angry and fighting. He wet the bed a number of times, b/c someone thought to not put a foley cathether in him in the OR. Depending upon how you looked at his situation, you could have fought it either way; but given the current attention to cauti infections, this position could be quite sensible. The cuff leak test is often done to predict the probability of laryngeal stridor. Both parents were nearby and very attentive to the five year old child. My suggestion, although it was somehow grossly distorted and met with outlandish outrage, was to perhaps back off of the sedation a little and allow the child to interact (yes while the ETT was still in) with his parents and try to use the urinal. My position was that he would be moving around, and movement, in light of all the meds he was receiving, may help to mobilize accumulation of fluid as the meds are working, and in time, he might be more apt to develop a significant airleak, without having to keep him ultra sedated on versed and fentanyl. Worst case, if he was too wild and stressed, we could re-sedate until he could be reassessed for cuff leak. The parents were very appreciative of this perspective, and I had worked in other hospitals and seen such approaches work. I hated to think it, but it seemed to me, since the census had been low in that unit at that particular time, they wanted to keep this kid as long as possible. Of course I can't prove that, and I don't want to be unfair. But I have seen a lot over the years.

    At any rate, a former adult nurse who had made her in-roads in that unit as "somebody" and the manager's "informant" started a huge issue over it. Now I had had a ton more critical care peds experience than she, but I was trying to keep my mouth shut. I made a possible suggestion, but rather than calmly and critically thinking about the possibility, even if the plan was not going to change, they were drilling me loudly, bringing undo attention, and basically just trying to get me to fight and look like an arse. I stated I shared one perspective, but that it is ultimately up to the doctor, and I am fine with the plan as it is. I just offered another perspective, with the potential to bring the child to the previous level of sedation if that what needed--but again, its up to the team and not me. The point is, even though I was moving on to another patient and other situations, they would not let it go. It was completely intention and was an attempt to undermine me, my thinking skills, and my safety of practice. I never said, "Hey, let's just extubate the kid right now." NOPE. Not even close. It was a well, disguised, bullying game. I had seen it before in other places. I smiled, kept my mouth shut and continued to move on; but the handful of nurses were not going to let it go, and they had the nurse manager convinced that I was some kind of nutjob or something. It was incredibly ridiculous.

    At the end of the day, the people that were guilty of poor critical thinking in that situation were the troublemakers. They couldn't conceive of anythink short of sedating the hell out of the kid for God knows how long. When I spoke to the fellow anesthesiologist--their initiation, not mine--he looked at me as if to say he saw my point of view, but the numbers were against him, so he quoted some piece of research from years before and hauled butt out of their. People knew how toxic that unit could be--even anesthesia fellows.

    The problem was that they could not think in terms of what was put forth to them, but rather jumped to conclusions about what was suggested. And not only was this poor critical thinking on their part, it was, to some degree, intentional sabbotage. On that day I decided I would work on continuing my education such that I could move out of nursing. That kind of closed-minded and intentionally misconstrued and manipulative thinking made it clear to me why this is not the field for true thinkers in such environments.

    Don't get me wrong. I am CERTAINLY NOT saying nurses don't engage in highlevel thinking, and absolutely critical care nurses have to do this on a daily, if not hourly basis in their roles.

    It's just too so hard to find the right team of nurses that aren't trying to undermine or outdo each other, but less come together with some sort of unified, "think tank" approach to things. It's like some can't think this way or they just won't. Either way, those that are really into higher level thinking are push down and trampled on by those that can or will not think and discuss, objectively, without other perspectives in mind.

    As long as nursing is dominanted by people that refuse to grow or just cannot grow in this capacity, those that have and would use the ability to think with varied and higher-ordered thinking will often be trampled over. Some environments allow such thinking and openness; but too many do not. In over 20 years, I have not seen a great deal of change in this direction. And this issue, at least in part, is the lack of ability for nurses to engage in building coalitions rather than embracing fractions or cliques. Sadly, too many nursing administrations want it that way --that way they can hold on to tigher control of nursing. They control the dominant players and have them limit the others. Again, I have seen this played out over decades.

    I am fundamentally against this type of leadership and thinking. Thus, my hope is to be out of nursing in the next several years. I have loved much of what I have done in nursing, and the patients, families, many other nurses and healthcare personnel, and physicians. But the way these kinds of things are encouraged and show no signs of changing, I can't deal with the toxic and limited thinking anymore.

    Critical thinking? I like this fellow's perspective on what it is:

    What is Critical Thinking?

    No one always acts purely objectively and rationally. We connive for selfish interests. We gossip, boast, exaggerate, and equivocate. It is "only human" to wish to validate our prior knowledge, to vindicate our prior decisions, or to sustain our earlier beliefs. In the process of satisfying our ego, however, we can often deny ourselves intellectual growth and opportunity. We may not always want to apply critical thinking skills, but we should have those skills available to be employed when needed.
    Critical thinking includes a complex combination of skills. Among the main characteristics are the following:


    We are thinking critically when we
    • rely on reason rather than emotion,
    • require evidence, ignore no known evidence, and follow evidence where it leads, and
    • are concerned more with finding the best explanation than being right analyzing apparent confusion and asking questions.


    We are thinking critically when we
    • weigh the influences of motives and bias, and
    • recognize our own assumptions, prejudices, biases, or point of view.


    We are thinking critically when we recognize emotional impulses, selfish motives, nefarious purposes, or other modes of self-deception.


    We are thinking critically when we
    • evaluate all reasonable inferences
    • consider a variety of possible viewpoints or perspectives,
    • remain open to alternative interpretations
    • accept a new explanation, model, or paradigm because it explains the evidence better, is simpler, or has fewer inconsistencies or covers more data
    • accept new priorities in response to a reevaluation of the evidence or reassessment of our real interests, and
    • do not reject unpopular views out of hand.


    We are thinking critically when we
    • are precise, meticulous, comprehensive, and exhaustive
    • resist manipulation and irrational appeals, and
    • avoid snap judgments.


    We are thinking critically when we
    • recognize the relevance and/or merit of alternative assumptions and perspectives
    • recognize the extent and weight of evidence
    In sum,
    • Critical thinkers are by nature skeptical. They approach texts with the same skepticism and suspicion as they approach spoken remarks.
    • Critical thinkers are active, not passive. They ask questions and analyze. They consciously apply tactics and strategies to uncover meaning or assure their understanding.
    • Critical thinkers do not take an egotistical view of the world. They are open to new ideas and perspectives. They are willing to challenge their beliefs and investigate competing evidence.
    Critical thinking enables us to recognize a wide range of subjective analyses of otherwise objective data, and to evaluate how well each analysis might meet our needs. Facts may be facts, but how we interpret them may vary.

    By contrast, passive, non-critical thinkers take a simplistic view of the world.
    • They see things in black and white, as either-or, rather than recognizing a variety of possible understanding.
    • They see questions as yes or no with no subtleties.
    • They fail to see linkages and complexities.(This has been a big one for nursing, in my view.)
    • They fail to recognize related elements. (Another big one.)
    Non-critical thinkers take an egotistical view of the world
    • They take their facts as the only relevant ones.
    • They take their own perspective as the only sensible one.
    • They take their goal as the only valid one.

    -- Daniel J. Kurland

    How do you truly develop this in nurses. I mean if critical care nurses buck against this whole realm of thinking, what hope is their for the profession in this regard?

  • Dec 4 '12

    I think you don't need to try to anticipate which questions are appropriate or proper to ask. As the previous poster said: ask the questions as they arise. If you come across anything that you do not understand, either research it or ask it in order to give adequate care to your patients.

    For instance, you get a new admit to your Med/Surg floor. You have the patient history that gives a diagnosis with which you're unfamiliar. Either look it up (preferable if you have the time) or ask a more experienced nurse. By asking a co-worker, you will (hopefully) receive not only the low-down on the disease but also how to give care, what care to give, what to anticipate by way of orders from the MD and what the patient's course of recovery likely is.

    Bottom line: if you don't know something about your patient, the diagnosis, the meds or the care required, ask questions or do your research. Do not sacrifice patient care because you were embarrassed to ask a question.

  • Dec 4 '12

    Exactly. There is no secret list here of appropriate questions. Anything you do not know is appropriate and you don't know what you don't know until you run into the wall of not knowing it. It is part of critical thinking to acknowledge what you do not know and part of the learning process to discover what you should know but don't. You can't anticipate what you don't know ahead of time because you can't anticipate what any given patient will have going on, on any given shift. You have to experience the patient and the situation and use them to learn. It is vulnerable and hard and scary. It is great you want to be prepared but this is why it is said that you don't really start learning how to be a nurse until you hit the floor working as one.

    My first patient ever with my preceptor on my first shift ever was desat-ing when we went into the room for bedside handoff. I had no idea what to do including where to even hook up O2. I had to ask about that as well as how to call for a rapid response.

    The next day one of my patients had a BP of 209/110 when I arrived. I went into a shaky hyper freakout because I had no idea what to do. I had to ask about that.

    Another patient had a BUN of 71 and the lab called with that critical value. I didn't know what to do with that information and had to ask.

    It just comes with time. You can't do it ahead of time. The only way to the other side is through.

    Good luck. You will survive it and you will do great.

  • Nov 27 '12

    Quote from DSkelton711
    I am just so tired of being a nurse. I feel like I am running on fumes trying to take care of everyone and everything, and it seems nothing ever goes right. I am done, cooked and ready to do something else. Does anyone else feel this way? What do you do to overcome it? I am 52 and blessed to be employed, but just don't know that I want to be a nurse anymore.
    I hear you. I've been a nurse only 2 years and I'm considering other career options. It's not that I don't enjoy's the system and the politics which can be energy sucking. What about taking a vacation, going PRN or community nursing? Ultimately, we must take care of ourselves in order to properly care for our patients.

  • Nov 27 '12

    I am just so tired of being a nurse. I feel like I am running on fumes trying to take care of everyone and everything, and it seems nothing ever goes right. I am done, cooked and ready to do something else. Does anyone else feel this way? What do you do to overcome it? I am 52 and blessed to be employed, but just don't know that I want to be a nurse anymore.

  • Nov 17 '12

    Quote from LTCnurse11
    The whole deal is that I know I'm interested in acute care and like the learning, but I'm not 100% the right time for me. I only was there 3 months and was burned out from nursing school and the EMT program right after. I really want to be sure I don't force myself into another mistake. I am feeling very upset about having been terminated and I think part of me wonders whether or not I'm cut out for it. I know I can do it. I just need more training or something. I also would like to have the option to further education by obtaining that benefit.
    I am curious.....what made you get your EMT right after school? What career path are you looking at?

    You said you had up to 4 patients......unfortunately that isn't a lot of patients for a med-surg floor. I think you need to gain control of the basics before the next step. What was your struggle? My new grads have trouble with organization.....brain are a few.

    mtpmedsurg.doc 1 patient float.doc‎
    5 pt. shift.doc‎
    report sheet.doc‎
    day sheet 2 doc.doc

    critical thinking flow sheet for nursing students
    student clinical report sheet for one patient

    I made some for nursing students and some other an members have made these for others...(.Daytonite)....adapt them way you want. I hope they help

  • Nov 17 '12

    Are you sure you want to work in an acute setting? It is 100% okay to not do it. I know, so often we are told to get that med/surg experience, and I do encourage it, but maybe you found out early that it isn't for you. I've worked in a few hospitals and I'm grateful for the experience and confidence it gave me, but I don't miss it and have no desire to go back. I'm not a hospital nurse and THAT IS OKAY!!!! I like corrections....I like hospice.....I like school nursing.....and so on!!

    Just make sure you are really doing it because you WANT to and not because you think you should. There are GREAT nurses that are successful and happy outside of hospitals

  • Nov 17 '12

    Quote from LTCnurse11
    The whole deal is that I know I'm interested in acute care and like the learning, but I'm not 100% the right time for me. I only was there 3 months and was burned out from nursing school and the EMT program right after. I really want to be sure I don't force myself into another mistake. I am feeling very upset about having been terminated and I think part of me wonders whether or not I'm cut out for it. I know I can do it. I just need more training or something. I also would like to have the option to further education by obtaining that benefit.
    My first job was ICU. Never did do med/surg. Although I feel that is the meat and potatoes of nursing I'm not sure I would have made it through it. With your EMT education and interest, maybe you should focus on ICU rather than floor nursing. Before you do anything though, really look deep into yourself and find out how you can improve. If you were constantly asking questions, more than "normal", then yes that could be a sign of lack of confidence and/or knowledge. It also drives people crazy. So while I think you should definitely ask questions, remember you made it through school and you should take an initiative to look up something and educate yourself. Think hard about what you really want to do. Good Luck.