05.08 Thinking Like a Nurse

We're going to talk about thinking like a nurse. This is something you've heard before. People telling you, "You need to start thinking like a nurse." I'm going to show you how. And we're going to start pulling this together, from things that we've learned in these previous lectures, leading up to this point.

Nichole tells the story all the time about a student she had one time when they were in simulation. So they got this high-fidelity manikin. Things start going bad. The patient starts crashing. And the students are in there freaking out. One of the students turns around to Nichole and says, "Get the nurse! Get the nurse!" And she looks back at him and she says, "You are the nurse."

Guys, you guys are the nurse. You're the one taking care of these patients. So it's important that you start pulling all these skills that we've talked about together, and you realize you are the nurse.

So how do you think like a nurse? And what does that even mean? What does it mean to think like a nurse? With any decision, you must carefully consider the consequences. What is the evidence that you have? What are the implications if you do something, and if you don't do something? What's going to happen to the patient?

This is really critical thinking. You can go back to our critical thinking lesson to understand that more. And go back to the nursing process ones. You're always thinking and you're always anticipating. You're thinking a couple steps ahead. If this happens, then what? If this happens, then what? That's really part of thinking like a nurse.

It's also important as a nurse to think about, what is your scope? What are you even allowed to do? As an RN or LPN, what does your state practice standard say? What can you do? What are you allowed to do, in general?

Now, what can you do, without an order? What do you need an order for? And then think about, can I do this? Do I need an order for this or do I not need an order for this? If you don't need an order, you can implement it. If there's something that you do need an order for, then when you're calling the physician, make sure you have it laid out: what it is that you need and what you want to have happen with this patient.

Now, what orders do you already have? A lot of providers will write standing orders. If this, then that. If this, then that. Know these orders ahead of time. Know the policies and procedures at your hospital. A lot of hospitals will have care maps for different disease processes. If those are already in place, can you work with those? Rather than spending and wasting time trying to find orders and get orders made, do they already exist? Are they already in your chart and can you already start doing things without having to call and get new orders?

You also need to know your limitations. If you need help, ask for help. The scariest nurse on the floor is the one who never asks for help. And I think that you'll hear every experienced nurse say that ... The scariest student, the scariest new nurse, the scariest practicing nurse is the one who never asks for help.

I was asking for help all the time. We had our pagers. We had our phones. One thing I would always do is if I was in a patient's room who couldn't speak or whatever, I would keep the call light close to me because I know as soon as I push that call light button, it's going to the front desk and they're going to pick up immediately and I would say, "Hey, I need you to call X. I need you to call Y. And I need you to get them into room seven," or whatever. Ask for help. Be willing to ask for help. And make sure you do that often.

If you don't know something, look it up. Your hospital, your facility, your school should have resources available for you. The NRSNG Academy is also a wonderful resource if you don't know something. Have your mobile app ready, have your scrub sheets ready, so that you can look things up at the drop of a hat to find it. You don't need to know everything, but you need to know how to find information.

Then, make sure you speak up. Don't be that person who stays quiet if you feel that things are wrong. If you don't understand an order, if you don't understand why something's going on, speak up. Providers make mistakes too. Providers are in a hurry, also. Providers have all these different patients they're taking care of. Be willing to speak up. Don't be the nurse that sits silently by the bedside and just listens.

Now, nursing is a lifelong career. As a nurse, you're a lifelong learner. Start practicing this now. Start learning everything you can and realize that it's okay to not know. It's okay to ask. It's okay to find more and new information.

Now as a nurse, you need to be using the nursing process. I realize that what you're thinking right now in nursing school is, "As soon as I'm done with school, I'm forgetting the nursing process and I'm never going to use it again. I'm never going to use a care pan." But like we've talked about in other lessons, the nursing process is used. Whether you like it or not, this is the way that you start practicing.

What I notice is a lot of students come out of school and they say, "I'm never going to use the nursing process. I'm done with it." But then they start getting lost as they practice as a nurse. They start feeling lost on the shift. And then they realize that things start making sense. Things start clicking. Things start fitting together. And what they've started doing is they've started using the nursing process without even realizing it.

Assess, diagnose, plan, implement, and evaluate. We do this all the time. We're always doing this. Just realize and start to embrace it, rather than thinking of it as something that you are going to abandon in your career.

Another important skill as a nurse is to anticipate. Always be thinking two steps ahead. What do you think is going to happen or could happen with this patient? Get ahead of a problem before it even becomes a problem.

Think about your patient's needs. What might this patient need or want? If you've ever heard the story, "If you give a mouse a cookie" ... if you haven't read that story, maybe read it. If you give a mouse a cookie, they're going to want this, they're going to want this, they're going to want this. That's kind of how it is in the hospital.

You want to avoid having to make as many trips as you can, as many phone calls to a provider as you can. And you want to try to address all those patient needs in one sweep, and address all the provider needs in one sweep.

If you have a patient whose blood pressure is going down, don't just call a provider and then you say, "Hey, let's start him on vasopressors." You hang up the phone, you go back in the room, you realize they need a central line. Anticipate what's going to be needed.

If you called prior and they say, "We need vasopressor," say, "Hey, you know what? We don't have a central line. I'm going to need that too." Get that order and get that taken care of. Try to anticipate as much as you can. This is one of the most important things that you can do as a nurse because things change, and things change rapidly.

Then develop a routine. We're going to talk about a morning routine. When we say morning routine, it doesn't have to be your morning. It's your beginning-of-shift routine. If you have a routine, you'll know where things are supposed to be and how things should be done. So when things start going off of that routine, you can start recognizing those anomalies and say, "Hey, something's not right. Let's get back to here." "Something's not right. Let's get back to here." And so it's really important that you have that routine.

At my house, I have an exact place where I always keep my keys, my wallet, my ChapStick, and my phone. And my kids know that. And I can even ask them now, "Hey, where does Dad keep his phone?" They know exactly where it is. It's right by my nightstand with all those other things that I put in my pocket every single day. If those things aren't there, then I know something's off.

Plan out your day. Plan what you're going to do. This goes back to anticipating your patient's needs. And then, assess the same way every time. Have a head-to-toe assessment routine that you always follow.

Check out the nurse routine lesson on this as well. That's going to help you a lot. But have these processes. Have these ways of doing things so that you know that whenever things are happening contrary to that, and you can fix them immediately.

Now, sometimes you just know something isn't right. Trust yourself, trust your training, and trust your gut. In the neuro-ICU, we've got a lot of patients who would come in and things usually kind of went the same for every patient. We had this one patient come in though, this younger guy. He had just had a fall and things didn't seem right with him.

So I call the physician, I call the provider. I say, "Hey, I believe this patient's going to need a ventric tonight. I'm just letting you know. Here's the CT." He looked at the CT and ... you know, it looked normal, it looked fine. He was responding okay, but he just didn't seem right. Lo and behold, just four hours later, the physician had to come in and put a ventriculostomy in to help that patient relieve some of that pressure.

So trust your gut. It's okay to think that things are going to be a little bit different. It's okay to have these feelings. Trust that gut and understand that that's your role as a nurse, is to provide care, but also to look for anomalies and look for when things look a little bit different.
So thinking like a nurse involves always thinking. Thinking about consequences, of action and inaction, and then always anticipating. What's going to happen next?

To think like a nurse, make sure you know your scope and your limitations. Make sure you understand those things so you don't start acting outside of that.

Then, follow the nursing process every time. A-D-P-I-E. We're going to beat that into you. I realize you might hate us for that. But following ADPIE is so important.

Develop a routine. Plan ahead. Anticipate needs. And try to do the same things the same way, every time, so that you can know when things are getting off of that routine and you can bring it back quick.

And then, trust your gut. Sometimes, you just know.
All right guys. I want you to refer to the other lessons that talk about the nursing process, that talk about the nursing routine, that talk about critical thinking. Those are going to help you greatly.

Please understand that we want you to succeed. We want you to be very successful when you first enter the floor. So refer to all the different resources and tools in this lesson. And trust yourself.

All right guys. Go out and be your best selves today. Happy nursing!