Critical Thinking - Need Help!

[jennsrn]

I am a nurse with just about a year and half experience as a working RN. My first position was working LTC/skilled nursing, and I absolutely hated it. I felt I didn't learn much and I was overwhelmed more and more everyday. I left and found a subacute RN position and so far I've been there a little over 6 months. I think it's a good job to get some decent experience, but I still feel like I have not progressed. I still feel as though I lack many critical thinking skills and I have many stupid moments that I look back at and ask myself why I didn't catch that or think of that. I have great support from my nurse managers and DON, but my self-esteem has greatly been affected. I find myself comparing myself to other nurses, and am amazed on how well they are able to catch on to changes in a patient's status and know the steps to take. Doing this makes me feel stupid. There are days I still have crazy anxiety going into work, but then there's days I feel like I can conquer the day and what comes with it. 

My primary issue that I feel like I'm struggling with is critical thinking. Nursing school does not teach you how to critically think, and I know it sometimes takes longer for some, but as a nurse for a year and a half already, am I just slower, or is this something that will never come to me? I work on a subacute floor, where I can have up to about 16 patients if the unit is filled. I find it incredibly hard to keep eyes on all patients, know patient hx, background, etc. My med passes can sometimes be heavy, then having to deal with wound tx and doctor's orders,  I end up feeling extremely overwhelmed at times, where I'm begin to rush to just get everything done. I work 8 hour shifts and I feel myself a lot of the times rushing to get it all time that I forget what the purpose of me being there and why I became a nurse in the first place. I feel as though if I were to work in a setting where the ratio is smaller, I would be able to take the time, learn my patients, and actually work on my nursing skills. Many of the times, I walk into the room, introduce myself, get vitals, do a quick look over, and move on to the next patient. Some of the patients, as sad as it is, I only see a few times in an 8 hour shift. It sometimes leaves me feeling unaccomplished and disappointed. 

Regarding critical thinking, I had a patient the other day where I walked in and got vitals. I got a BP of 204/80, and an oral temp of 102.5. I rechecked manually and got 190/76. Looking at her diagnosis, she was admitted for septic arthritis, and was being treated with IV ABT. I assessed for pain, gave her her IV ABT, scheduled Coreg, oxycodone for pain, and Tylenol for pain. I figured her BP was raised because she was running a fever and was in severe pain, and after looking at her BP trends, she did usually run on the higher side. But seeing this high number put me in panic mode. I quickly notified my supervisor and told her we should contact the doctor. Granted she was on BP medications, but it was a relatively small dose, so I felt it was right to reach out to the doctor. The supervisor told me to recheck the BP, and temp in two hours before reaching out to the doctor. What is your take on this? I also feel like because I go into panic mode, my first reaction is to call the doctor instead of critically thinking and asking myself why this may be happening. Sometimes I jump at it before looking at PRN orders, or the patient's background and medical hx. I am also scared to make myself look like an incompetent idiot if I were to call the doctor unnecessarily. Thankfully her BP did decrease to the 130s, and her fever did break, but was I overreacting? I am scared to make a mistake, not take initiative, and feel like an idiot. I also still struggle with identifying situations that warrant a doctor's call versus me working through the problem myself. I feel as though I need to just stop, take a breath and critically think problems through. Any advice on this? I need to work on my self-esteem and not be so nervous. 

[JBMmom, MSN, NP]

Take a deep breath. Really, take one. It sounds to me like you've answered your own questions at the end of your post. You're right where you should be after six months on a very busy unit.

People talk about critical thinking like it's a magical skill that needs to be taught or learned. If you look out the window in the morning and it's raining do you grab your flip flops or your boots? Critical thinking. You're coming to a light and it turns yellow, do you slow down or speed up? Critical thinking. You can do this because with time, assessing your patients will become as second nature as dressing for the weather or driving around town. But it does take time.

As far as your particular situation, do you have order parameters for notifying the MD of certain changes in condition? In that particular situation, I don't think that either of you were right or wrong. You could have notified the MD and you probably would have gotten similar orders to what the charge RN said, but at least you know the provider was aware. Or, you could wait and see whether your interventions, pain meds, Coreg and tylenol, were successful, which they were. Your reasoning was sound for suggesting you call and her reasoning was sound for holding off. Sometimes it will also depend upon the time of day, which provider is the attending, etc. Many factors go into these things. 

For sure you could use a boost in your self esteem. Try to leave each shift and think about something that went RIGHT. Because I bet you're going home and playing over in your mind all the things that you think went wrong. You're probably doing better than you think in a challenging position. Give yourself time and grace. Good luck!

[JKL33]

On 3/29/2021 at 6:36 PM, jennsrn said:

I feel as though I need to just stop, take a breath and critically think problems through.

On 3/29/2021 at 6:36 PM, jennsrn said:

I need to work on my self-esteem and not be so nervous. 

You've got it figured out. Now you just need to do it. When you feel panic coming on, remember that the place is not going to go up in flames while you take 60 seconds or 2 minutes (or more) to think things through and decide what to do next.

You've made a good self-assessment here. That is also something significantly in your favor. You're doing much better than it sometimes feels like. Imagine all you are going to learn now that you've put this puzzle together and know that you need to process your assessment findings and think them through.

It's all good. ??

[NicelySeasoned]

You got some good advice from colleagues here. Try to use it. You seem to be intelligent. Don't beat yourself up because you didn't learn something in school that you needed. Critical thinking can take time to master. It took me time to learn how to teach it. For a long time, if you asked 3 people what it was, you got 4 different definitions. We can nail it down a bit better now. But it is still a deep subject. The right class, the right mentor, the right environment can all help learn critical thinking.

You might benefit from a residency program. I would have recommended that to you as a new grad. Many of them will focus on the skills you feel you are lacking in. You can get there eventually, but many residency programs help the new grad to work and learn at the same time and to focus on skills that are not taught in school and are essential to survive in nursing. I am not telling you to quit your job, just look into a residency program.

Keep the faith.

[SmilingBluEyes]

On 3/29/2021 at 6:36 PM, jennsrn said:

Regarding critical thinking, I had a patient the other day where I walked in and got vitals. I got a BP of 204/80, and an oral temp of 102.5. I rechecked manually and got 190/76. Looking at her diagnosis, she was admitted for septic arthritis, and was being treated with IV ABT. I assessed for pain, gave her her IV ABT, scheduled Coreg, oxycodone for pain, and Tylenol for pain. I figured her BP was raised because she was running a fever and was in severe pain, and after looking at her BP trends, she did usually run on the higher side. But seeing this high number put me in panic mode. I quickly notified my supervisor and told her we should contact the doctor. Granted she was on BP medications, but it was a relatively small dose, so I felt it was right to reach out to the doctor. The supervisor told me to recheck the BP, and temp in two hours before reaching out to the doctor.

What is your take on this? I also feel like because I go into panic mode, my first reaction is to call the doctor instead of critically thinking and asking myself why this may be happening. Sometimes I jump at it before looking at PRN orders, or the patient's background and medical hx. I am also scared to make myself look like an incompetent idiot if I were to call the doctor unnecessarily. Thankfully her BP did decrease to the 130s, and her fever did break, but was I overreacting? I am scared to make a mistake, not take initiative, and feel like an idiot. I also still struggle with identifying situations that warrant a doctor's call versus me working through the problem myself. I feel as though I need to just stop, take a breath and critically think problems through. Any advice on this? I need to work on my self-esteem and not be so nervous. 

Bolding and paragraph break mine.  It's much Easier to read in paragraphs. Sounds to me as if you already know the answers. When you feel you are in a panic it's always wise to take a deep breath, step away, even for only 60 seconds or so. THEN think. And always be willing to bounce questions off more experienced colleagues or the supervisor in the future. You are learning; you don't know it all and are not expected to.

FOCUS. BREATHE. STEP AWAY for a minute. It clears things up very effectively.

Good luck.

[LibraNurse27, BSN, RN]

16 patients with IV meds and other semi acute issues sounds really tough. I actually did see critical thinking in your post. You thought about why the pt was having abnormal vital signs and you thought about what to do! Calling the doctor wouldn't be wrong, and as @JBMmom mentioned, you will figure out which doctors like to be called for every little thing and which only want to be called for emergencies (doesn't mean you can't still call them when you feel it's necessary though!) To me it sounds like you did everything right = ) Over time you will see patterns and gain experience, and feel more confident. 

[Hannahbanana, BSN, MSN]

Critical thinking develops when you have enough experience to see patterns. You get just a tiny bit of this as a student; not counting the time you weren’t in your current job, you’re not that far from new-grad-ness. This isn’t a bad thing, but it is a thing. 

Before you take that deep breath, exhale. That helps you see and plan more than you might think. Then, when you feel your mind threatening to run away with you screaming in its wake, exhale, think a specific thought: “In three years this won’t matter,” and proceed. 

You will find that you will become more aware of priorities (a major building block of critical thinking) when, like in the insurance ad, you’ve seen a thing or two. I agree c above posters that you sound intelligent and well-spoken. If you don’t already, subscribe to a few of the better nursing mags and read them cover to cover. You’ll be gratified to find how many little tidbits and useful minutia will come out at work when you least expect them, because you learned it in a no stressful moment relaxing at home. That will help your self-confidence too.

Short term goals: one hour of calm per shift- not just absence of panic, but actual calm. When you discover to your surprise you have achieved that, new goal: 2 hours, not necessarily consecutive. Eventually you will reach those too. 

Finally, indulge an old broad here. 
I’ve told this story before but this seems a good place to repeat it. When I was a year out of school I took a job in a real hot-shot ICU, big stuff every day. It was a challenge. I was so nervous and felt so inadequate when so many others were just cruising. One day I was in the break room before report with Sarah, a very seasoned nurse of 8 years there who could do anything, was always in control, could handle whatever gawdawful mess rolled into her room.

I asked her, “When do you stop feeling scared?” She said, “I feel a little anxiety every day when I come in before report. When I stop feeling that is when I’ll know I have to quit.” 

Anxiety releases catecholamines from your adrenals that dilate your pupils to see better, increase your heart rate and contractility to support increased activity, and release glucagon from your liver to feed your muscles and brain. These are all good things, whether you’re facing an actual tiger, impending sepsis, or an angry family member or surgeon. Be aware of this, work c it.

It’s OK to be a little anxious. But remember what it says on top of the mayonnaise jar: Keep cool, do not freeze. We’ve all been there. You’ll be OK. 

[Glycerine82, LPN]

For me, I think about what the doctor might do If I called immediately versus if I try xyz intervention and then call with all of the info. 

Sure, I can call with a high BP but what Is the MD going to say if I've also just given a BP med besides re-check?  

When I was new I usually would run my thought process and rationale by my co-workers if I wasn't sure.  I still do. 

[love2banurse89, BSN, RN]

I agree with all of the above! Many times you have good evidence & both/either answer is right as for calling the Dr. 

My first year in nursing school, 35+ yrs ago, a very seasoned instructor gave us advice that has stuck with me ever since. (Miss Cheney had never married or had kids. She did, however, have cats, & told us about having to give one of her cats an enema. I figured that I had better take the advice of anyone who could give her cat an enema!) 

Her words of wisdom were “treat the patient, not the paper.” In other words, consider the patient not just the numbers. Was your patient w/the fever & high BP alert & oriented (or at least at his baseline)? Or was he declining and confused, etc? Were respirations easy or labored? Was he able to eat, drink, communicate, take meds? Or lethargic, difficult to arouse, in pain,  unable to take in liquids? Obviously your assessment findings will also determine whether the Dr should be notified NOW or can wait to see the effectiveness of interventions. 
 

I applaud you on rechecking the BP manually—automatic BP cuffs can be so inaccurate; I usually take BPs manually. If I get a very high temp I also check if the patient has just taken a drink of coffee or soup. ? 

sounds like you’re doing a great job on a busy unit! Try to count your successes every day—getting meds given on time, explaining a Med or diagnosis to the patient or family member, learning about a new med. and-as mentioned above—when you are feeling so anxious, STOP, close your eyes, and take a few deep breaths! 

[vintagegal, BSN, DNP, RN, NP]

You will never lose your license alerting the physician. You will lose your license if you fail to recognize an issue and fail to move it up to a higher level of care. So what if the physician gets upset or grumbles that he doesn’t want to be bothered? At least you let him know of a potentially dangerous situation. CYA is what I always say because if we don’t cover ourselves and protect our patients then what are we doing ? Your an excellent nurse! Keep up the great work! 

[Glycerine82, LPN]

3 hours ago, vintagegal said:

You will never lose your license alerting the physician. You will lose your license if you fail to recognize an issue and fail to move it up to a higher level of care. So what if the physician gets upset or grumbles that he doesn’t want to be bothered? At least you let him know of a potentially dangerous situation. CYA is what I always say because if we don’t cover ourselves and protect our patients then what are we doing ? Your an excellent nurse! Keep up the great work! 

True, but I know in my line of work, notifying the MD multiple times in a night would cause me to be late with my other patients in addition to pissing the MD off - which for me is reason to try to wait until I have more information if appropriate and if I’m likely to need them again for other patients . 
 

not saying they shouldn’t be contacted - OF COURsE if in doubt - do it. But IMO learning when and why to call can really make a big difference overall. 

[nb1104_, ADN]

I can totally relate to this! I’ve been a nurse for almost 2 years but have moved from job to job but now that I am doing medsurg after more than a year (had 5 month medsurg experience as a new grad), I am struggling! Am I stupid or is this part of the new nurse journey. Like today, I have 2 patients in 1 modified contact room. A bed is confirmed c. Diff patient but the B bed does not have c. Diff not anything to be isolated. How didn’t I catch that?  I just feel extremely stupid, I had 12 hours to think of it yet I didn’t! I was also in a panic mode because A bed is running a fever. I noticed that every time I do have a situation going on, it ruins my focus. Is critical thinking automatically embedded in a nurse’s brain once he/she graduates? Am I like this because I almost failed nursing school too? All I can think of to improve myself as a nurse is to read books about medsurg nursing, go back into my recordings from school. I just feel like I failed as a nurse today, defeated! I want to be a competent nurse.