As a non-health care provider, I don't understand this doctor's complaint about nurses, as it's beyond my scope of knowledge. But I'm sure there will be rebuttals from some of you here.
One of my biggest irks about the nursing profession is their failure, at times, to use critical thinking skills. Some nurses are much better than others. Some floors are much better than others and in fact, some floors I give rock star status. I would trust them with my life to do the right thing. And then again, some nurses are incapable of comprehending what critical thinking is. I'm not sure if this is because of the rules and regulations by the hospital or government imposed safety regulations or simply something that isn't remembered from their school days or even that it isn't taught anymore (a scary thought).
What happened to critical thinking in the nursing profession? Is the nursing profession to blame for turning some nurses into robotic like documenteurs, void of any critical thinking skills? Or is it the toxic malpractice environment that drives robotic like activity?
Example: I had a patient with a BP of 94/52 pulse was 48. Pt was a DNR, terminally ill. BP had been in that range for the last 3 days. I held the 100mg of lopressor scheduled (order was 100mg lopressor BID). Nobody had been giving this guy his lopressor for 3 days because the BP was in the toilet. Nursing judgement 101 -- if Systolic less than 100, Diastolic less than 60, or pulse less than 60, hold BP meds. No, I didn't call the doc, he'd been in to see the patient, could see the BP was in the toilet since right in front of him on the 24 hour summary is posted right in front of the doc in the wallroo we keep the chart in. It wasn't like this was a sudden change in the patient's BP.
Doc sends the patient to the NH, NH gives the ordered med WITHOUT checking the BP, patient crashes and dies. My NM calls me in, reads me the riot act about "practicing medicine without a license" because I held the med. I told her if I'd given it, I would have been practicing negligent homicide. She really couldn't understand why I didn't give the med. We know what happened when someone did.
While this is true, I think that it can be handled. I've had the pleasure of working with some excellent docs for many years. Most appreciate when they are approached with the problem and with a potential solution. I think they appreciate a nurse who can determine "if" a call to him is truly needed. I've heard nurses call doctors for the most ridiculous things and then get mad when the doc is less than nice on the phone. Really, do you need to call a doc at midnight for a wound care consult that you KNOW isn't going to happen until the morning?
I'm finding a real lack of a solid anatomy and physiology background in new nurses. Without that critical thinking isn't going to happen.
Also, I think that without proper knowledge about pathophysiology critical thinking wont happen...
This reminds me of the whole "is nursing a profession" topic. I've often felt that in some nursing schools that professional demeanor is not established, that would lead a nurse to take pride in their work, be a life-long learner, communicate effectively with other members of the team, and generally function as a thinking professional.
Also, there are some countries where nurses do not have the same role and expectations as in the US. If as a nurse in their country they functioned as a handmaiden and were not expected to critically think, why should nursing here be any different?
There needs to be more guidance other than passing the NCLEX to help these nurses assimilate to new professional expectations. This is not a slam on foreign nurses, just a suggestion towards more help adjusting to the role.
This reminds me of a nurse from Ukraine,who when I questioned the order about an insulin,replied "Give it because the doctor wrote an order!
This reminds me of the whole "is nursing a profession" topic. I've often felt that in some nursing schools that professional demeanor is not established, that would lead a nurse to take pride in their work, be a life-long learner, communicate effectively with other members of the team, and generally function as a thinking professional.
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See, these last kind of posts really misdirect the issue, I think.
I don't think the problems we are discussing have much to do with actual knowledge deficits of nurses or a lack of understanding of just what is critical and worthwhile in determining priority of care/interventions/physician calls, etc. It's the ROLE itself and the limititations inherit to it. Frankly, at times I think many programs overreach in their depth in relation to the actual job. Don't misunderstand, more education is always a plus but at times here what you know and what you are required to do can vary wildly.
I mean let's get real, it's all nifty and fine and dandy that I/WE know what meds/labs/whatever ('critical thinking')needs to be begun but if there are systems in place that don't allow, encourage or respect that input, we're just back at square one. Yeah, I know you know what labs, for example, to call. There is often no room built in to make those decisions w/out violating random policy. Now doc is annoyed and you are perepetuating the 'stupid' stereotypes....yep, good set-up....And sure, many mold these restrictive practices by learning provider preferences and building trust, etc. It's just unfortunate we need to 'play games' like this and cross our fingers that the back up will be consistent and our licenses/jobs stay safe.
Oh,BTW, I don't think nurses should be autonomous, though I think this is probably why I gravitated toward ER because there is much independence thru protocols and I don't feel quite as tethered as it were.
But it's not what skills/education/thinking MOST nurses are bringing to the table that is the problem here---it's the place settings already laid out for us.
We need to stop navigating and accomodating the status quo for the sake of system process when these actions just keep us out there doing the RIGHT and LOGICAL practices but ultimately functioning without a net....or a rope if you know what I'm saying....
Everytime I have failed to use my brain it was because I was being pulled in so many directions at once I could even spell my own name let alone think in a coherent manner. Docs can complain all they want about lack of critical thinking skills but let us face it, it is not going to change unless something is done about these ridiculous patient ratios.
I think ratios are the scapegoat and not the panacea.
My facility has a med/surg ratio of 4:1 and an IMU ratio of 3:1, yet I still see lapses in thinking on a daily basis.
Here's some stuff from this very week:
Med/surg nurse initiates the rapid response team, reason: "hypotension". Patient's BP is 98/54 at team arrival. Worse, their baseline the past 24 hours was 100-110 systolic. Even worse, the nurse had just given the patient (new hip fx awaiting surgery) 5 mg morphine 20 minutes prior.
Med/surg nurse initiates the rapid response team, reason: "hypoglycemia". Granted, the patient's BSG is 53, but the patient is awake, alert and oriented, and is able to tolerate PO intake perfectly fine. Even worse, there's already a PRN order for 1/2 to 1 amp of D50 as needed (not even needed here due to tolerable PO).
I call (in my monitor tech role this time) and tell a nurse her patient's heart rate is sustained SVT rate ~175. She very snidely states, "Oh, he's probably just in the restroom." Click. She hangs up on me. I have to call the charge nurse to actually get somebody in the room to assess the patient.
General surgeon inserts a PICC line. Patient states, "My heart feels tickled" during placement. Surgeon walks away stating it's okay to use. I ask the nurse (nursing student hat this time) if we should get an X-ray to confirm placement. She tells me matter-of-factly that if he didn't order one, we don't need one. I go behind her back, page the surgeon, and get the telephone order for one (luckily we can take orders last semester here). X-ray report comes back-- shows the distal tip of the PICC inside the right ventricle. Nurse upset I won't hang patient's antibiotic piggyback despite PICC placement in ventricle.
That's in one week, in facilities with good ratios. Draw your own conclusions.
I think ratios are the scapegoat and not the panacea.
My facility has a med/surg ratio of 4:1 and an IMU ratio of 3:1, yet I still see lapses in thinking on a daily basis.
Here's some stuff from this very week:
Med/surg nurse initiates the rapid response team, reason: "hypotension". Patient's BP is 98/54 at team arrival. Worse, their baseline the past 24 hours was 100-110 systolic. Even worse, the nurse had just given the patient (new hip fx awaiting surgery) 5 mg morphine 20 minutes prior.
Med/surg nurse initiates the rapid response team, reason: "hypoglycemia". Granted, the patient's BSG is 53, but the patient is awake, alert and oriented, and is able to tolerate PO intake perfectly fine. Even worse, there's already a PRN order for 1/2 to 1 amp of D50 as needed (not even needed here due to tolerable PO).
I call (in my monitor tech role this time) and tell a nurse her patient's heart rate is sustained SVT rate ~175. She very snidely states, "Oh, he's probably just in the restroom." Click. She hangs up on me. I have to call the charge nurse to actually get somebody in the room to assess the patient.
General surgeon inserts a PICC line. Patient states, "My heart feels tickled" during placement. Surgeon walks away stating it's okay to use. I ask the nurse (nursing student hat this time) if we should get an X-ray to confirm placement. She tells me matter-of-factly that if he didn't order one, we don't need one. I go behind her back, page the surgeon, and get the telephone order for one (luckily we can take orders last semester here). X-ray report comes back-- shows the distal tip of the PICC inside the right ventricle. Nurse upset I won't hang patient's antibiotic piggyback despite PICC placement in ventricle.
That's in one week, in facilities with good ratios. Draw your own conclusions.
All I can say is holy crow! ARE the nurses getting "less critical thinkers?"
Sometimes, when reading threads here, I often feel like I work in a Utopia compared to most of you.
We do have some decent standing orders for stuff, or very comprehensive admit orders, but it's nothing like what it used to be 1998-2003ish when I first got into the healthcare field. Back then, I remember the ICU nurses having dang near unlimited standard orders, plus easy access to the meds. There's a limited amount of stuff that's available on override nowadays, compared to the pre-computer controlled access.
random thoughts on why critical thinking seems lost...
CYA,
nurses on the floor are not allowed to use judgement, I heard "someone" telling one of the doctors he could no longer write and order for 1 or 2 whatever pain med. talk to joint comm,
ICUs "do" interventions because like someone said, they have to do it now!!
Hopefully they "know" their docs.
Some docs don't care if you cath a pt at 3 am and some do.
It seems as nurses either have 20 years of experience or less than 5, newbies don't always know which docs to trust. I've seen it happen.
Bingo!!!! Doc A doesn't want to be called for a bicarb of 43 on a patient with COPD but Doc B comes in screaming the next morning because no one called him when his patient's temp went up to 100F. Some docs micromanage, some don't. I got so sick of trying to accomodate all these different personalities and figure out how to "handle" the various docs.
I'm finding a real lack of a solid anatomy and physiology background in new nurses. Without that critical thinking isn't going to happen.
I can confirm this amongst my classmates. I even in one project-based learning exercise poked a bit of fun about the fact that stuff I'm covering they should have known from A&P. The way the that admission to the program was calculated, we were essentially required to have an A in A&P, but you wouldn't know it from my class. It disappoints me.
In my area of nursing, there is a lot of autonomy, and wide parameters that a nurse can function within. There is a lot of room to change the course of a pt's tx, change the meds and so on. The problem is that a lot of nurses don't have the knowledge, skills, and critical thinking needed to make the decisions and judgements that they are allowed to make.
I think ratios are the scapegoat and not the panacea.
My facility has a med/surg ratio of 4:1 and an IMU ratio of 3:1, yet I still see lapses in thinking on a daily basis.
Here's some stuff from this very week:
Med/surg nurse initiates the rapid response team, reason: "hypotension". Patient's BP is 98/54 at team arrival. Worse, their baseline the past 24 hours was 100-110 systolic. Even worse, the nurse had just given the patient (new hip fx awaiting surgery) 5 mg morphine 20 minutes prior.
Med/surg nurse initiates the rapid response team, reason: "hypoglycemia". Granted, the patient's BSG is 53, but the patient is awake, alert and oriented, and is able to tolerate PO intake perfectly fine. Even worse, there's already a PRN order for 1/2 to 1 amp of D50 as needed (not even needed here due to tolerable PO).
I call (in my monitor tech role this time) and tell a nurse her patient's heart rate is sustained SVT rate ~175. She very snidely states, "Oh, he's probably just in the restroom." Click. She hangs up on me. I have to call the charge nurse to actually get somebody in the room to assess the patient.
General surgeon inserts a PICC line. Patient states, "My heart feels tickled" during placement. Surgeon walks away stating it's okay to use. I ask the nurse (nursing student hat this time) if we should get an X-ray to confirm placement. She tells me matter-of-factly that if he didn't order one, we don't need one. I go behind her back, page the surgeon, and get the telephone order for one (luckily we can take orders last semester here). X-ray report comes back-- shows the distal tip of the PICC inside the right ventricle. Nurse upset I won't hang patient's antibiotic piggyback despite PICC placement in ventricle.
That's in one week, in facilities with good ratios. Draw your own conclusions.
I'm finding a real lack of a solid anatomy and physiology background in new nurses. Without that critical thinking isn't going to happen.
I can confirm this amongst my classmates. I even in one project-based learning exercise poked a bit of fun about the fact that stuff I'm covering they should have known from A&P. The way the that admission to the program was calculated, we were essentially required to have an A in A&P, but you wouldn't know it from my class. It disappoints me.
I'm a pre-nursing student, just finishing up my A&P2 lab this semester. It's been 5 years since I took A&P1 and A&P2 lecture. Of course I've forgotten everything I learned back then in A&P. I'm doing good in the lab, but it's all just memorizing the locations and labeling of things, not the way things work (I would have gotten that in the lecture 5 years ago). I've been concerned that no being "fresh" on this stuff will hurt me in the nursing program and as a nurse. But I've heard others (on allnurses) say that you don't really have to know much A&P to be a good nurse or get through the program successfully. I don't just want to pass through though, I actually want to be good at it. But I also don't want to take a whole class over again that I already passed with an A. What do you think I should do?
nerdtonurse?, BSN, RN
1 Article; 2,043 Posts
A fish rots from the head down.
Example: I had a patient with a BP of 94/52 pulse was 48. Pt was a DNR, terminally ill. BP had been in that range for the last 3 days. I held the 100mg of lopressor scheduled (order was 100mg lopressor BID). Nobody had been giving this guy his lopressor for 3 days because the BP was in the toilet. Nursing judgement 101 -- if Systolic less than 100, Diastolic less than 60, or pulse less than 60, hold BP meds. No, I didn't call the doc, he'd been in to see the patient, could see the BP was in the toilet since right in front of him on the 24 hour summary is posted right in front of the doc in the wallroo we keep the chart in. It wasn't like this was a sudden change in the patient's BP.
Doc sends the patient to the NH, NH gives the ordered med WITHOUT checking the BP, patient crashes and dies. My NM calls me in, reads me the riot act about "practicing medicine without a license" because I held the med. I told her if I'd given it, I would have been practicing negligent homicide. She really couldn't understand why I didn't give the med. We know what happened when someone did.
Scary.