HELP!!! Need advice to critical think at work!!

RuRnurse? · Sep 15, 2009

You are a victim of nursing schools. They are HORRIBLE at teaching you what you actually need to learn. They focus on the "task", even 'docking' you points for not doing a particular "step"...They themselves miss the big picture!

In the real world of nursing, very few things will actually go the way you expect. In lab, you are dealing with a mannequin, in real world, it is a person, with oddities, personalities, and uniqueness. Even in hands-on clinical, you have, at best, a couple of "patients" on whom to practice what you've learned.

So, when the new grad actually ends up in the real world, what a shocker! The highest turn-over rate in my place is among new nurses. Nursing schools need a real makeover, need to start teaching the skills people will actually USE in practice. Otherwise, we will continue to have folks graduating from nursing school, only to find they don't have the stuff they need to actually do the job.

MikeyBSN · Sep 15, 2009

I agree, nursing schools are very task-oriented. It's also hard to teach people the "big picture." I noticed that you were in CCU, did you start in CCU? It's a pretty tough place to start. No doubt that your pt's have a wide variety of complex needs and you might feel a little overwhelmed. Perhaps you might benefit from spending some time on tele or stepdown?

cloister · Sep 15, 2009

Hey, it takes time.

We've got a real big crop of brand new ICU nurses working with us now as we prepare to move to a bigger unit. The majority of them are struggling with the same issue you're struggling with. I can see the frustration behind their eyes when I talk to them as a preceptor or mentor.

They're all smart, hard-working, conscientious people, and they're going to make great nurses. Most of them haven't been nurses for very long, however, so how can I expect them to think like seasoned veterans?

That being said, I'll offer my two cents on what worked for me as a new ICU nurse:

1) Ask questions. Ask lots of questions. Ask questions even when you think you know the answer. I was always amazed at the extra info I was able to pick up and squirrel away for future reference.

2) Find a mentor. Look for someone who's clinically excellent and approachable. Ask them to take you under his/her wing. Many experienced nurses are honored to be asked, and it also serves the purpose of making you somewhat off limits to those who would put you down. I know I tend to be a little territorial about my preceptees and mentor buddies.

3) Play "Worst Case Scenario, Patient Care Edition", when you have a spare moment or two at work. Pause from the mundacity of the bath or flowsheet to ask yourself, "What will I do if this patient goes into V-tach?" "Drops in front of me?" "Has a seizure?" "Blows her aortic graft on a wound vac?" (Actual situation in my ICU. Luckily, I had thought about it a few days before!) It kind of makes me stop and think of what steps I need to know to be prepared later. Of course, I always emerge as the cool thinking heroine in these mind trips.........

4) Read. No, I don't mean textbooks - you've read enough of those for now, I'll wager. Read the $6.99 paperbacks you find with names like "Critical Care - The Story of a Nurse", or "Intern", or "Tales from the ICU". Stories are a great learning aid. Let's face it, you learn far more from hearing about somebody's screw-up than you do from a treatise in a journal. It's also way more fun as you think to yourself, "Well, at least I haven't done THAT."

5) Go easy on yourself. It takes time, observation, and experience, both good and bad, to develop the judgment that leads to critical thinking. The fact that you acknowledge your preceptor's comments without being defensive shows that you're open to learning and hearing what others have to say. That alone makes you more intelligent than a lot of folks. Frankly, nursing needs more folks like you.

Hope some of these ideas help, or at least make you laugh a little! Good luck to you. :wink2:

HouTx, BSN, MSN, EdD · Sep 15, 2009

IMHO, you are working with very sub-par preceptors. It is a preceptor's job to provide clarity - to ensure that you really understand the performance goal & to provide direct and indirect assistance to get you there.

Rather than using ambiguous terms like "big picture", you deserve to be told specifics. Exactly what is the performance gap? Are you not catching on to the underlying physiology (e.g., when blood pressure drops, you should expect heart rate to increase & this could cause pacemaker failure if leads aren't sensitive enough). Do you have a problem with prioritization - getting caught up in a laundry list of tasks rather than sifting through them to determine which should be done first?

Don't beat yourself up. Ask for more specific information about your remaining skill / performance gaps. Ask what criteria will be used to judge your sucess? If you arent't getting anywhere with your preceptor, talk to your manager... if that does not work, make an appointment to talk to HR.

ktwlpn, LPN · Sep 15, 2009

3) Play "Worst Case Scenario, Patient Care Edition", when you have a spare moment or two at work. Pause from the mundacity of the bath or flowsheet to ask yourself, "What will I do if this patient goes into V-tach?" "Drops in front of me?" "Has a seizure?" "Blows her aortic graft on a wound vac?" (Actual situation in my ICU. Luckily, I had thought about it a few days before!) It kind of makes me stop and think of what steps I need to know to be prepared later. Of course, I always emerge as the cool thinking heroine in these mind trips.........
:

That is the best advice-I'll be passing it on...

wooh, BSN, RN · Sep 15, 2009

The Worst Case Scenario is good advice. I always look at what's going on with my patients. I think through, best case scenario this will happen. Then think through the most likely complications. And then think through the worst complications that could happen. I can then prioritize my "tasks" for what will be the most effective interventions to a) get to best case scenario and b) prevent complications.

esthomprn · Sep 16, 2009

Thanks you guys. These are some helpful hints but here are some answers to you quesitons. Yes, I started on the CCU unit but when I was a tech I was on med/surg unit cause I was told that you have to have 1 year of experrience so I i thought this would help. Here are some of the things that happened for them to say this.

1. had a patient on the vent and I turned him. Next thing you know his PIP raised. First thing I thought was check his vitals, see if everything is correlating, see if he's blue. After check everything (which was normal), my preceptor finally came in and found out that when I turned him the tubing kinked. She said after 10 weeks I should have recognized what to do and that she's sure I had PIP increase (uummm, no. everytime the PIP goes up on my patients in the past it was cause they coughed)

2. day 2 of having a patient on EVD and she said that she had a headache. I thought to give her pain meds. after a couple of hours she was still having headaches. My preceptor came up to me and asked me did I check the level of the external EVD. I forgot to check it that morning. She said that it was 1 inch above the level it was suppose to be. Felt really bad about that and I didn't think that maybe she was having headaches cause of increase ICP

3. had a patient that had CP and he would desat. First thing I thought was increase O2 but my preceptor said that was part of his condition and he is use to it so just give him a minute. He came back up. Next week had a patient who would desat after he coughed cause he couldn't swallow. He coughed and he desated so I waited a minute thinking he would cough it up. my preceptor said i need to deep suction him cause he can't swallow. I understood that but he could still cough and thought he would cough it up.

4. did chart check like i do everyone morning. Preceptor looked at the emar and asked me did they d/c this one med (day 2 of having him). I said wasn't sure. she looked at the chart and there it said it was d/c. she said that i should have known that when she asked me but here is the thing. the nurse that gave me report went over the chart with me (like we are suppose to do) and she stated that it was d/c and said that she scanned it to pharmacy so it was done. Plus she crossed it out on the flowsheet. If they d/c a med, why would i try to remember if they did it or not. To me, i have more important things to remember.

and that's just a few. i'm glad there are telling me these things cause i told them I don't want to be "that nurse". the one that everyone says "oh man, im getting report from her". so i want them to tell me when i'm doing wrong. My confidence is just shot down :cry:

MedSurgeMess · Sep 16, 2009

take a step back and look at the big picture--yours--you're new to the area as a nurse, so slow down. At 3 months you should be getting it somewhat, but they shouldn't expect you to act like a veteran of 20 yrs! Start writing things down. Critical thinking comes from experience, and this is the best way to track your experience! I commend you for asking questions, instead of becoming defensive as another poster mentioned. Good luck, just remember to breathe and keep notes

PostOpPrincess, BSN, RN · Sep 16, 2009

Thanks you guys. These are some helpful hints but here are some answers to you quesitons. Yes, I started on the CCU unit but when I was a tech I was on med/surg unit cause I was told that you have to have 1 year of experrience so I i thought this would help. Here are some of the things that happened for them to say this.
1. had a patient on the vent and I turned him. Next thing you know his PIP raised. First thing I thought was check his vitals, see if everything is correlating, see if he's blue. After check everything (which was normal), my preceptor finally came in and found out that when I turned him the tubing kinked. She said after 10 weeks I should have recognized what to do and that she's sure I had PIP increase (uummm, no. everytime the PIP goes up on my patients in the past it was cause they coughed)
Now you know about kinked tubings. Go and review ventilators and all the safety issues that go with patients on vents. MEMORIZE THEM.
2. day 2 of having a patient on EVD and she said that she had a headache. I thought to give her pain meds. after a couple of hours she was still having headaches. My preceptor came up to me and asked me did I check the level of the external EVD. I forgot to check it that morning. She said that it was 1 inch above the level it was suppose to be. Felt really bad about that and I didn't think that maybe she was having headaches cause of increase ICP
Where is your book? That is basic to the assessment of a neuro patient. REVIEW

3. had a patient that had CP and he would desat. First thing I thought was increase O2 but my preceptor said that was part of his condition and he is use to it so just give him a minute. He came back up. Next week had a patient who would desat after he coughed cause he couldn't swallow. He coughed and he desated so I waited a minute thinking he would cough it up. my preceptor said i need to deep suction him cause he can't swallow. I understood that but he could still cough and thought he would cough it up.
Again, this is basic. REVIEW AIRWAY management.
4. did chart check like i do everyone morning. Preceptor looked at the emar and asked me did they d/c this one med (day 2 of having him). I said wasn't sure. she looked at the chart and there it said it was d/c. she said that i should have known that when she asked me but here is the thing. the nurse that gave me report went over the chart with me (like we are suppose to do) and she stated that it was d/c and said that she scanned it to pharmacy so it was done. Plus she crossed it out on the flowsheet. If they d/c a med, why would i try to remember if they did it or not. To me, i have more important things to remember.
Wrong. YOU are the person who needs to follow up. Do not depend on report alone. That's why it is a 24 hours chart check. Go back to basics.
and that's just a few. i'm glad there are telling me these things cause i told them I don't want to be "that nurse". the one that everyone says "oh man, im getting report from her". so i want them to tell me when i'm doing wrong. My confidence is just shot down

Confidence is down? Good, in a way. You can now be taught.

Look, I will be blunt. You need more time. You need more time with basics. You need more time to remember. Does that make you a bad nurse? Nope. Just that you need more time. Ego aside, it is better for you in the long run.

I've worked with nurses who had to take the "curvy" road to learning ICU. Guess what?? They are DAMN GOOD nurses.

Fact: You have to reconcile with that and accept it. Put away the ego, and learn. Be open to learning.

If this is a generational thing, put it aside, put your ego aside, and BE OPEN.

Whenever I precept, my expectations are very high. However, I do not expect that everyone goes at the same speed. I slow down with some people. I speed up with others.

It is the way of the world. Suck it up. Put on your big girl panties and keep going.

Jo

esthomprn · Sep 16, 2009

Thanks again for the advice but one last thing. In nursing school we learned anytime a patient desats you give them O2 (of course after knowing that there is nothing in the airway and the pulse ox is on correctly and all that). we were never taught that it depends on the patient medical condition.

And on a side note, decided to transfer to a general med floor so that I could get the basics down. I put my ego aside a excepted that that is the best thing for me to do and when i'm ready i will go back. I just need to learn to critically think on the next unit

greenfiremajick · Sep 16, 2009

i'm glad there are telling me these things cause i told them I don't want to be "that nurse". the one that everyone says "oh man, im getting report from her". so i want them to tell me when i'm doing wrong. My confidence is just shot down.

Something comes to mind.....You stated you wanted to hear criticisms. They may be heaping everything they notice on you, since you asked for it.