How to develop ICU critical thinking skills and move away from being "task" focused

Da_Milk_of_Amnesia, MSN · Jun 27, 2014

Critical thinking skills can be taught or learned from a book. It's something that comes with time and experience. (this is just my opinion) I think critical thinking comes from a understanding of basic and some advanced physiology, pharmacology etc. But a lot of this is just from experience.

Here's something to think thru that I had to go thru and since I had no idea what was going on I learned it and never forgot it.

For instance, If you have someone with a blown mitral valve. What do you want to do?

Well think about it. What's wrong, first of all? Blown segment - every single heart beat is shooting blood back into the plum. veins and the patients lungs are literally filling up. You need to get more Blood moving forward right.

So what would you give? The answer: Vasodilators and eventually an IABP

Why? You need to decrease the after load, blood is going to go in the path of least resistance. If you decrease the resistance in front of it, you'll make it want to preferentially go that way.

- Idk if that help, but thats one way to go thru things. There are hundreds of ways to skin a cat and you'll eventually learn one of the ways. There are other things you can do as far as time management goes. I used to pull out all my meds at the beginning of the shift (if i had a whole lot to give) we had little places where we could hide them in the room so we did. I just made sure to label and double and triple check against my MAR. There are many other little tricks that you can do to cut down on time. You will learn them as you go, I know you can give meds up to 30 to 1 hr before right? If i could I would always give stuff early but within reason. I would also chart things that i knew were not going to change, like if the patient had a swan, I know my temps are all going to come from that so i'd go down the line and click whatever box it was. IT's little things like that, that will help you save some time. Some people may disagree with me or not. Take what you want from it and use it if you like it. The bottom line is that you're not going to learn it all, no one can 'teach' it to you and you can't learn it from a book. You either got it or you don't and right now you don't. You're going to have to work your ass off, so get moving.

Esme12, ASN, BSN, RN · Jun 27, 2014

I get frustrated by these statements when they cannot give an improvement plan and examples of what they feel you are doing wrong.

It takes time to develop that all encompassing ICU focus. Four months isn't long enough. You are very task focused at first it's survival. It is a learned process and takes time.

My suggestions. Go home after work or on break (If you get one) look up disease processes. Start to make the connections. Give me an example...and I will try to walk you through. When I started in ICU...I would come in early (after discussing it with my manager) not clock in and look at the patient charts. I would read the MD/consult H/P and progress notes of the patient I will be getting or the patient I had the day before. With all the fear of HIPAA (which is an unjustified fear) they "need to know" has been interpreted as ....if you are not actively caring for the patient don't go in the record...which is sad as that is where you learn.

Multitask when getting report. I like to have the computer open to click around in as I get report. This has annoyed some nurses...they feel I am not paying attention...but I can repeat verbatim every word they have said. As I check orders I glance at the progress notes for the previous day. When I give meds I think of why I am giving the med and how it effects the patient.

You are stressing yourself. I am willing to bet you already do this but don't know how to verbalize it to their satisfaction.

midnitej · Jun 28, 2014

Thank you for your advice Da_Milk_of_Amnesia. I agree with your post and I have been doing just what you have mentioned over the last week. I am in the process of finding ways to improve my knowledge to help improve my critical thinking skills with reviewing disease process and management. I Just think it has taken me a long while to try to figure this out on my own and my unit has the opinion that I am "behind the times" as it was stated. In my opinion, I just think I need more time to develop and from reading different posts it seems reasonable that 6 mths - 1 yr to get my groove and that it will take another yr to be more comfortable. I guess with being on the unit for 7 mths (3 months of orientation and 4 months on my own) I have not proved myself to the unit but I have been working to expedite the learning curve to help facilitate being a better ICU nurse. It has been tough because no one told me what I was doing so I had to figure things out on my own and develop my own plan. Please don't get me wrong as I am not trying to make excuses and I know that it is my responsibility to facilitate my own learning and take charge it was just confusing to think I was performing well and then being told otherwise without having any specifics.

midnitej · Jun 28, 2014

Thank you Esme12 for your advice. I have in the past went in early to look at my assignment but stopped because the assignments were not always done and at the time I didn't realize that I could have been violating HIPPA so I will speak to my manager and get permission because now that I realize my mistakes and understand that having the time to read over the pt's H&P and notes from the MD's and ancillary staff would help me to focus on the whole picture until I get the hang of organizing my time to incorporate this without having to come in early. Also since I didn't fully understand the importance of looking at the whole picture to understand the management of the pt and started being "task" focused and not realizing and understanding the "why" I was doing the "task." In addition to this, I would be frustrated that I could not articulate to the CN or when giving report which I was all over the place because I was so scattered brain and would have my co-workers and CN be annoyed with me.

You are absolutely correct as I was in "survival" mode and reverted back to my ED ways of being "task" focused and not taking the time to breathe and relax and think about the whole picture as to why the pt was here and what would I expect the management to be in order to fix the pt and understand why I was doing these "task." I just think that it has taken me longer than my counterparts who have gotten their groove early than I did but in my opinion they had more direction and help than I did. Please don't take that last statement like I am making excuses because I know that it's my responsibility to facilitate and take charge of my learning which is what I have done over the last week now that I finally see where I was lacking and have been reviewing disease processes and what to expect the management and complications so I am hoping to bridge the learning curve in the ICU and improve my critical thinking and knowledge and keep working on managing my time while focusing on the whole picture.

Your statement about "stressing out" is absolutely correct because I was in this mode for about 3 weeks trying to figure out what I was doing wrong and frustrated about not having any feedback as well. I also could not focus because of the fear of being asked to leave the unit however after talking to friends I was able to communicate what I was doing, how I didn't have the time to see the whole picture and was behind because I was just trying to do "task" and not being able to communicate what was going on with the pt or the POC and how I would get frustrated and didn't have a plan and that's how it came about starting over like a new grad and reviewing disease processes and looking at the whole picture and taking it a step further by seeing things as a provider would as some of my friends are in NP school and explained to me how they had to make this same transition from RN to provider. I realized my previous RN experience I didn't look at the whole picture for example in the ED I just focused on the primary issue and understand that one issue and knew the "task" or management of that pt. In the PCU, I must admit that I didn't think as a provider but I think because I was able to make the transition and take care of the pt's I didn't have the same pressure like I am experiencing in the ICU.

Now that I have stopped stressing and being fearful of being asked to leave. I am now focusing on my plan with looking at the whole picture like you mentioned and hopefully I will bridge the "you're way behind" that has been mentioned to me and will show great improvement on my unit.

ilikesharpthings · Jun 28, 2014

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Ruby Vee, BSN · Jun 29, 2014

Esme is absolutely right about studying in your free time. You absolutely cannot learn to put it all together in a complicated environment like the ICU without spending some time studying on your own. The good news is, as you become more experienced and learn more, you have to spend less and less time studying at home. Or on your break.

As far as learning critical thinking skills -- you should be understanding the rationale for every intervention and every medication you give. It's not enough to turn your patient every two hours -- you have to understand WHY you're turning your patient. WHY are you giving that Coumadin through the PEG tube when the patient is also on a Heparin drip? If you don't understand why you're doing something, either look it up or ask. Read the H & P -- they'll explain a lot of what is going on. Read the consulting service's notes. Make sure you understand your lab values. It's not enough to know that the INR is 6.7 unless you can relate it to the cherry red urine and the rapidly dropping hemoglobin. It takes more time and effort at first to understand the whys, but the advantage is that you start to be able to put it all together a lot faster.

Good luck.

calivianya, BSN, RN · Jun 29, 2014

Ruby Vee said basically what I was going to say - you need to ask why about absolutely everything you are doing and giving, and why the physicians write the orders that they do, and get your coworkers involved in your thought processes! Use your coworkers as resources and talk over patient care with them. Having someone double-check your thinking will teach you a lot about how to critically think in the first place, and will point out the things you are missing.

A good example happened just the other day for me - my coworker had a patient with a persistently high heart rate, no fever, seemed adequately hydrated (was making great urine), her pain was under control, etc. I was sharing a perch with this coworker so I ended up being very involved in caring for his patient. We had done labs, but no mag level. He had called multiple times about her heart rate and we did an EKG, which the physician can read over the intranet. The physician ordered 2g magnesium sulfate IV and neither of us could figure out exactly why, so we looked up magnesium on Lexicomp. It's not like we didn't know what it was or what it did, but odds are the physician was giving it for a reason, right? Maybe there was a reason we didn't know about. It said nothing about using mag for high heart rates in our drug reference. He refused to give it without a mag level from the lab, and so we drew more labs. The mag level did indeed come back low, and he hung the mag.

We were still wondering how the physician had made the jump to order mag just based on an elevated heart rate without a mag level when a coworker was walking down the paper copy of the patient's EKG to us. We mentioned it to her the whole confusion over the mag, and she just out and said, "Well, this EKG says the patient has a really long QTC interval." Prolonged QTC -> risk for Torsades -> Torsades is treated with mag, so we came back to the conclusion that the physician must have looked at the EKG and thought the patient's mag might be low because of the prolonged QTC. Or maybe she didn't assume the mag was low since other things can cause a prolonged QTC interval and just wanted to reduce the risk of the patient going into torsades because her QTC was so long. Either way, even with two heads put together we were still barking up the wrong tree when it came to figuring out what was going on. The two of us were fixated on the patient's heart rate when it was the characteristics of the rhythm we should have been looking at. Sometimes critical thinking really happens best in groups. Besides, the side benefit of critically thinking in groups is that your coworkers see that you are working on your critical thinking... which can trickle back to your manager and show that you are really focused on fixing your problems... it's a win-win situation.

marienm, RN, CCRN · Jul 3, 2014

I'm a new nurse, just about to finish my 1st year on an ICU that that cares for burn patients primarily. Our hospital doesn't have step-down units, so we also have SD patients on our unit...and sometimes we also have floor patients who just haven't been moved yet. I work nights (8s and 12s). I'm still struggling with time management too!

I think it's problematic that people are telling you that your critical thinking skills aren't up to par but are not giving you any specific examples. Can you think of specific cases where you missed a change in patient condition because you were so focused on getting through your "task list?" Or do they (whoever they are) mean that you're not using your critical thinking to organize your work? For example, getting a q2hour PTT drawn on time is probably more important than doing mouth care exactly every 2 hours, even though the mouth care is important and does need to get done. If the patient has q2 PTTs ordered, the doctors are probably watching something important or you're titrating a drip med.

Does your unit do bedside reports? Seeing the patient in front of you might help get your thoughts moving when you get report, and also let you ask the outgoing nurse more specific questions, including "does the team know about that?" (However, even if the previous RN says, "yes, I told them about it," if it's something you think is unusual, you should probably call them again! I've run into this a couple of times, complete with an irritated doctor because I *didn't* call them.) You also might be able to do a quick eyeball-survey of the room--check the dates on the IV tubing so you know if you need to change it, see whether you need to bring in more linen or a new toomey syringe for the NG tube, etc...

Depending on the atmosphere of your unit, remember that nursing is a 24-hour gig. If you didn't bathe your patient because their blood pressure was low and you spent a lot of time with the doctor on the phone, and then hanging boluses and/or albumin and/or a pressor, pass the bath on to the next shift! Hopefully they won't give you a ton of grief about it--you were dealing with the more important issue.

I definitely think the more experienced nurses on my unit are better at combining tasks than I am (but I'm getting there...). With a vented, sedated, stable patient, I like to do my assessment at the beginning of the shift (after reviewing orders and making sure there isn't a med due right then). I also do some mouth care, ET suction, check an NGT residual, peri/foley care, and (ideally) get help turning the patient so I can look at their back and also reposition them. If I can do all that, I feel like I've definitely seen everything I need to file my assessment (what color is the sputum? how about the NG aspirate?), and I've also gotten a bunch of tasks out of the way.

Our hospital changed computer systems earlier this year, which definitely set me back a bit in terms of charting! I'm getting used to some tricks that make it a little faster, though...like which flowsheets allow you to copy whole columns into a new time column (copy all of my 0600 IV assessment in the 0700 column at 0615...chances are it won't change by 0700, and I'll edit it if it does).

Hope some of this helps...just some various thoughts based on my last year of learning!

Stratiotes · Jul 17, 2014

I struggled with this for several months after moving to ICU nursing. While I have encountered the rare individual who simply does not seem to learn from experience, most people do. At first, everything in the ICU is so overwhelming, task based nursing is pretty much the only way one can cope! But once the tasks themselves are easier to handle, you can start flying on autopilot and focusing more on the big picture. Furthermore, as you experience more and more situations, you will begin to develop a greater awareness of your patients.

Let me give you an example. Not too far into ICU nursing, I had a post surgical patient who was breathing pretty fast. He was hurting, so it didn't concern me initially. I asked if he felt short of breath or if he was just hurting. He assured me he was just hurting. The pain medicine ordered was not relieving his pain, so I finally called for new orders. I mentioned to the physician the patient's respirations had been around 30 for a while, but like me, he chalked it up to pain. After giving the new meds, the patient reported his pain was better. Now I was starting to get concerned because he was still breathing really fast. I asked again if he felt okay. He assured me he felt much better. His other vitals were great, heart rate and rhythm perfect--absolutely no signs/symptoms aside from tachypnea. My gut was telling me something was wrong, but my lack of experience was leaving me without answers. I decided to draw my AM labs just after midnight and this guy had a potassium around 7.0. I immediately called and got orders to fix him, but in the few seconds it took me to draw up insulin, this patient went into vfib and coded. Of course, then it hit me that the patient had been acidotic and he'd been breathing fast to compensate, but having never seen such a case without any accompanying symptoms, that hadn't even crossed my mind.

Another night later on, I walked into a fellow new ICU nurse's room to help her turn her patient. The patient had been fine, but I noticed she was breathing really fast. The nurse said she'd denied pain and everything else was fine. Given the experience above, bells and whistles were going off in my head. I knew this patient was acidotic and we were able to get a blood gas and determine the cause long before it became a serious problem.

An experienced ICU nurse might say "Well, duh!" But, for the noob, you have to have some bad situations before you learn to recognize when patients are heading in that direction.

You'll get there!

delphine22 · Jul 19, 2014

Great examples here, please keep them coming!

Henrica80 · Aug 16, 2014

After reading this thread im rethinking my options, i just accepted an offer for CCU position but being an experienced RN on LTC and ZERO critical care, im assigned to 7 months residency program, 5 weeks of classroom and 22 weeks on the unit with preceptor. I graduated long time ago and i feel i have lost alot of skills being just on long term care for 7 years. I was also offered a position on orthopedic unit in a different hospital but since i have been so much interested on CCU, i was leaning towards CCU over orthopedic... i will appreciate on your advice before i make the wrong move...