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).
Regardless, from a training track that is advancing their agenda into areas of independent patient care via NP level training, there must be at least a basic foundation of learned critical thinking for all nurses in order to communicate effectively and efficiently on patient care. Nurses must be capable of handling some basic critical thinking skills. You don't have to be a super star. Just come to work with your thinking caps on. I get frustrated with the robotic nature of many nurses these days who turned in their thinking caps at the front door to hide behind the safety of the telephone notification.
Take for example being called at 4 am with a "critical lab value". It's would be interruptive to my daily schedule had the call happened in the middle of rounds at 1 pm. It's especially interruptive during the few hours of sleep I may get (if I'm lucky) on a night shift. What was that critical lab value? An elevated calculated bicarb level on an ABG of 43. Bicarb will always be elevated in someone who has chronic compensated CO2 retention (ie COPD) . Something that can be determined by looking at the ABG and using basic science skills to determine the acid-base chemistry. There is nothing critical about an elevated calculated bicarb level on an ABG of someone with a chronic compensated respiratory acidosis. It's only critical because the hospital must have a critical lab value cut off to report. Again, this is all legally driven medicine. Used to prevent lawsuits under the guise of quality.
I can actually understand calling me once with this non critical, critical lab value. I can't expect a nurse to always know such basic science skills and to differentiate the difference between a critical on paper and a clinically critical value, although it would be nice that their training gave them the critical thinking skills to figure it out on their own. It is quite scary to think that nurses graduating from nursing school going on to NP school have difficulty interpreting basic blood gas measurements. Incapable of making judgement calls between things that are critical and things that are not.
Regardless of the science, critical thinking skills should be used by the nurse to help them differentiate a critical value by definition from one that is really critical. And they should be allowed latitude in making the decision to contact the physician or not in regards to non critical, critical lab values.
But it appears that they are not. Maybe nurses must call all critical lab values, even though critical thinking would allow them not to do so. I explained to the nurse that this elevated calculated bicarb isn't critical, it's expected. I gave a telephone order not to call me the critical calculated bicarb level on the ABG and while she's at it, not to call me the actual measured bicarb on the BMP, because certainly, I was going to get a call about that as well.
The following morning at 4 am I got another page from the same nurse with a "critical lab value". An elevated calculated bicarb level on an ABG of 41. I asked her why she was calling me again. That this isn't critical. That an order was given the night before not to call me this noncritical critical lab value.
"I thought that order last night was just a one time order", she says.
Can anyone explain to me how taking an order not to call me a critical lab value that isn't critical can be a one time order when I have already been called?
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?
How do you fix this? And how do you prevent nurses incapable of critical thinking from entering into master's programs that require one to use critical thinking skills on a regular basis to prevent patient death? If nursing school no longer teaches critical thinking, what is the value in nursing education requirments? We can hire med aides and nurse techs to follow orders. That seems to be the road down which we are heading for. What happened to the nursing profession? Is it dead in the water?
What happened to on the job training & common sense? More time on the floors, more time listening, more more more. Even as a nurse, I am afraid of others taking care of me.
ReplyDeleteBoy, sure wish I had an answer to this quandry myself. If pressed, I'd guess that several factors are primary: lack of clincal time for students, the factory-line production of many A.S. nursing programs, the reduction of nursing to a recession-proof technical "trade", poorly educated foreign nurses who couldn't think critically even in their OWN language, and hospital understaffing while acuity rises. However, my personal observation is that the best and brightest get the HELL out of bedside nursing. I deal with bright and effective case managers, home health nurses, imaging coordinators and wound and ostomy nurses daily.
ReplyDeleteI'm with Neon--I take my hubby or a close nurse friend if I am an impatient. Its very scary, and the bar seems to get lower every day.
Pattie, RN
Hospital policy does require "critical lab values" to be called to the Dr and charted. This was a big thing not too long ago at work, making sure that nurses were calling within the required 60 minutes on all labs that came up and were marked as critical. However if there was an order, which most Docs figure out pretty quickly to leave, there was no reason you should have been called. Also a lot of time when you are familiar with the Dr you know what labs you really should call and what you shouldn't, regardless of what is labeled by the lab as critical. However on a Dr you don't know, I could understand following policy because you never know what will come back to bite you in the butt.
ReplyDeleteYeah, it's frustrating when the hospital sucks all the critical thinking skills out of an individual with all their stupid rules/regs.
ReplyDeleteThe chain I work for now - I guess you could call it the Walmart of hospitals - has a special charting section to verify we've called on "critical" labs, some of which are barely out of range. And there's no box you can check stating that a critical lab was not called due to whatever rationale. Wacky electrolyte on a dialysis patient? Gotta call it! Low H&H on a sickle cell who also happens to be a Jehovah's Witness? Gotta call it!
You do realize most nurses know that bicarb isn't concerning, but have no choice about reporting it, right?
ReplyDeleteI get annoyed when I look like an idiot for reporting a "critical" sodium of 143 in a patient who I just looked up and was 145 the day before, and I know there's nothing that can be done about the sodium more than what was already done.
The problem is with the system, not nurses as a whole.
Sorry, that should say 153, 155.
ReplyDeletethe problem is knowledge there are many people in health care system, that go in just "to be in there", doesnt care about basic science skills to determine the acid-base chemistry, there are people that just learn by repetition, not by inovation not by critical thinking.
ReplyDeletewell you could teach her, or why didnt you tell her that she should study a little bit more to know what is critical or what is not.
yet some people lack of interesting on improving their cognitive skills.
Or maybe the nurse doesn't like you and wants to wake you up.
ReplyDeleteI would love to get all up in your face defending nurses on this one, but unfortunately, I can't. (Besides, you're a blogger, you have no face). Some nurses have definitely lost critical thinking skills. Most ICU and ER nurses still have it (you will agree, yes?), but floor nurses, not so much. I have found that ICU nurses have better working relationships with the physicians, and they actually collaborate together in patient care. Nurses learn theory in school, but critical thinking is acquired on the job, and through experience. It needs to be mentored and encouraged. Common sense however, you're born with. Try as I might, I cannot teach common sense. As far as your dilemma with the critical lab value, if lab calls it critical, nurses have to notify the MD immediately, and chart that they are aware, no exceptions. We did not make up this rule, Risk Management did. You could always page the director of Risk Management at 3am with the critical lab value that's not really critical. How would that go over?
ReplyDeleteDr.Happy,
ReplyDeleteI physically can't get in anyone's face, unless I'm wearing stilettos and standing on a soap box. But enough about my social life. I actually work in a hospital that mandates physician notification of critical lab values. I have spent hours in medical records making sure nurses chart "MD notified", blah, blah,blah. A huge waste of time. I have also had critical labs called that are not critical, and even more scary, labs that are really critical not called, because lab does not think they are critical. For example a K+ level that is normal on a term infant, but critical in a preemie. You work in a more liberal hospital than mine. What is more concerning to me than lab values, is the actual physical assessment of the patient. Now that requires real critical thinking. Maybe nurses need a "residency" program on the unit they will be working on to tighten up these skill.
Only times Nurses bother me is when I deserve it... Don't want to be bothered with idiotic Hospital Rules? Private Practice is ready when you are...
ReplyDeleteThe problem is we are not allowed to think critically at times. Do I know that calling for a creatinine of 5.2 on a patient with ESRD is, well, pointless? Yes, but like others have noted, in order to "be in compliance" and keep my job...I HAVE to. It isn't a matter of not thinking, it's a legal thing. At least I'm one of the nice ones who calls with bogus criticals at 0655 instead of 0400!
ReplyDeleteLuckily though we were able to get an option entered as "Expected value, MD not notified" for situations like yours, enabling us to use our mad skills.
And please don't lump all floor nurses in on this one...
I think there are a bunch of reasons for this dilema. The risk management policies don't give nurses the chance to think anymore. But at least at my hospital we are given a check off box for a reason that we DIDN'T notify the physician if a value was critical.
ReplyDeletePart of the problem too is that nurses aren't given the proper orientation time needed when they leave school. Due to the shortage they are rushed into a position and put on their own taking care of patients. No matter what kind of program they are in AD or BSN they aren't taught the critical thinking needed in real patient care situations. That is learned over time and unfortunately at patient's expense (and sometimes at 4am doctor's expense).
What can we do to help it? Mentor our new nurses better when they are new graduates. Take them under our wings and teach them how to critically think in situations. This includes both nurses and doctors. So Happy, next time you get that 4am call do some teaching, not at 4am but maybe the next time you see that nurse, or the next morning etc. Teach her why that lab value wasn't important etc. It will probably save you the phone call the next time and will teach that nurse the beginning of some critical thinking skills.
as the wsj journalist wrote, i enjoy your blog for a different point of view as well. regarding ths post on nursing critical thinking skils...i often wonder the same about doctors. even as a new nurse i sometimes feel i 'get it' better than some residents. i wouldn't say its a matter of profession but just people are always able to somehow slide through systems. i agree there are some nurses who will not be taking care of my family, however i feel the same about some doctors...attendings included, not just residents.
ReplyDeleteThe phrase "critical thinking" is the politically correct euphemism for what used to referred to as simply "thinking."
ReplyDeleteRewrite your article with the adjective and it makes just as much sense.
pray tell since abgs results are quickly produced why was this poor patient having to endure an arterial stick in the middle of the night? what were you looking for? you stated yourself this was a chronic compensated co2er. put in parameters if you don't want to be called...we get dinged for not calling labs stupid as it is. also we play the game of what doctor wants what labs called
ReplyDeletewhen...since i work with geriatrics a gazillion consults and what one doesn't get exicted about the others will. I personally look at previous labs, progress notes to see the pphysician's plan and the actual presentation of the patient. a wise docotor said treat the patient not the numbers. just a lowly floor nurse here
A nurse trying to interpret an ABG is scary. Have you ever looked over the nursing literature regarding acid-base interpretation? Most of it is overly simplistic and miss mixed disorders.
ReplyDeleteI think you hit a nerve root here. Policy or no policy I am going to go out on a limb with you. I think that there are some nurses who absolutely rock the critical thinking skills and some that really should not be working on a med/surg floor. This year our lovely manager hired 3 non-critical thinkers that after 3 months of full time orientation are struggling with basic prioritization. I am kind to new grads but I think the kindest thing for the non-critical thinkers is to suggest day surgery. I have been a nurse for 14 years so I am not talking about the ones who just need a little time I am referring to the ones that are never gonna get it. Luckily they ask me or charge before calling labs/or MD about stupid stuff. Do we really need MOM or tums at 11:30 at night? Just order it under a patient that has it ordered go get it and give it to the patient that doesn't have it ordered. Wish I could order up some of the really basic crap like MOM, tums, colace, tylenol with a patient that has no risk factors.
ReplyDeleteJust want to throw out one of our hospitals policies. Blood sugars over 150 three times in a row must be called to MD. Does anyone care at midnight if it's not above 350 we can still cover it with SSI and leave a note for MD. Write a note and hold the call.
One more stupid policy. Urine output below 240 in 8 hours. If they just came from ER for nausea and vomiting for two days they are not gonna have urine or if they are in kidney failure they won't have urine. Post-ops sometimes produce lower urine. Critical thinking versus stupid hospital policy. The thing that sucks is explaining to the next shift why you didn't call so they don't freak out!
How about this... I am a student, second career, and was admonished by my clinical instructor that I was thinking like a doctor not a nurse when I wanted to get into physician's portal to get a better picture of a pt. with lots going on 2mo. post major trauma. Without portal, all we see is primary DX. What a joke. Its like driving blind. So much for wanting to critical think.
ReplyDeleteHappy, I agree with you. I'm a nurse, and I hate calling stupid stuff like positive troponins on my known MI pt. That said, my hospital is requiring this (blaming it on Joint Commission requirements, btw). We have been told we will be fired for not calling & documenting the call.
ReplyDeleteSo, I have resorted to asking for an order not to call any further XXX labs.
Here's one ICU RN that's in your corner...
Why don't you focus on your own profession and ask what happened to physicians treating their patients?
ReplyDeleteI have been a night shift nurse for years and I can't tell you how many times I or my co-workers have been sniped at by physicians when we call to report serious abnormalities.
It doesn't matter whether or not we're using our critical thinking skills and have our SBAR all together, including very specific recommendations.
We get yelled at.
SBP in the 60s? Must be because we're too stupid to take a blood pressure.
The admitting MD didn't bother writing for antiemetics on my N/V/D patient? It's still somehow my fault.
Fresh emergency X-lap that can't get the IS above 500 because all the surgeon wrote for is 1 Vicodin Q6, plus Morphine 2mg IVPush Q 4 hrs prn breakthrough pain-- well they're just going to have to suck it up because the MD is too pissy that I dared page him at 1 a.m.?
I only hope that every one of you MDs that pisses about nursing is someday lying in a hospital bed, as a victim of one of your unprofessional colleagues.
I must say reality rounds I disagree with your point. I find many floor nurses to be very competent without all the bells and whistles telling them what is going on (ie. ICU nurses) or an ER doc always in the same area to help them out (ie. ER nurses).
ReplyDeleteDr. Happy, your thread has been cross/posted on the AllNurses forum. There were lots of responses. The nurses are usually defensive when criticised, but most agree with you on this subject. Does this surprise you?
ReplyDeleteTake a look,
http://allnurses.com/general-nursing-discussion/what-happened-nursing-379539.html
Anon 9:46, nice ad hominem.
ReplyDeleteas you said happy, some nurses hide behind the "i have to call."
ReplyDeleteif you have to call, but know it's not critical, why not preface what you have to say by "i'm sorry to call you at this time, and i know it's not critical, but hospital policy dictates *insert lab value*"? or something like that.
i've had some nurses say something like that. that gives me a clue that, hey, things are ok with this patient, as the nurse gets it.
it's when you get a 4 am call about a creatinine of 5 in your patient who is on dialysis, when you get worried. because one starts to think that if the nurse doesn't understand that lab value for the patient, what else does he/she not get about my patient?!
again, if you know the value is abnormal and not a big deal, but HAVE to call, then just let me know that. it's those that don't know that cause this inconvenience.
Only teachers have a worse attrition rate than nurses. Critical thinking in nurses is like a case of "you get what you paid for"...you've seen the increased infection rates and patient deaths related to insufficient nurse staffing levels set by hospital administrators.
ReplyDeleteFortunately, this isn't my problem anymore.
This is the policy that most hospitals have in place, the hospitals not the nurses. No nurse likes calling these labs, especially the expected abnormal ones. I agree with the nurse that said if you are having these labs drawn every morning at least have them timed for after 0600 or reassess the need to have them done every day unless its an emergency like respiratory failure, that's pretty easy to spot, (this is where critical thinking comes into play). Please understand we do get in trouble for not documenting and calling these labs, we have management auditing our charting and it follows us through our evaluations. People have got in trouble for not doing so. If you the doctor wrote the order, then then hospitals policy comes into play which ties us into it. The labs that are ordered are processed by lab, they run it, then follow hospital policy by calling us, (pt soso has panic value.., critical high, oh can I have your employee id after your read that back to me, thanks..)that makes us call the oncall to notify them of the results. Oh, and saying Im sorry for doing my job gets old, we don't like it, you don't like, life sucks, get over it or do something about.
ReplyDeletedisappointed, no response. Guess I was right.
ReplyDeleteNurse-
I agree that nurse probably didn't have the necessary critical reasoning skills. However, as a nurse, it is all about documentation, documentation, documentation. If you show up during the day and document that phone order in the notes, there are clear parameters. Nurses like to cover their ass - if you want us to go against protocol or policy, it MUST be documented.
ReplyDeleteEg- Protocol says we must call a met call (code) if BP < 90mm Hg systolic. We have a lot of ascitic tap pts who come in every 2-3 weeks and sit at low BPs. Often the MO will write in the chart, not for met calls unless BP < 75 systolic (or <90 AND symptomatic). It's common sense but it's got to be in writing or we have to make the call.
I think it depends on the hospital you work at in regards to critical labs. When training at the hospital we were told no matter what we are to call critical labs to MD. I asked the same thing, what if it is a patient that would be expected to have critical labs? I was told we call it anyway to cover our butt. So unless the MD writes not to call we had to. Our doctors knew that and understood. Maybe someone shoud get a better attitude.
ReplyDeleteWhy do you return hospital phone calls? Because you have to, right? Or you would hear about it from the hospital administrators.
ReplyDeleteWe're in the same boat if we don't call critical lab values within 30 min of getting the results. It has nothing to do with the use of critical thinking skills. It's not a courtesy call. It's either call the lab value or possibly lose your job. Your crankiness isn't worth me losing my job.
As far as the nurse calling you back a second day in a row...well, I can't say much for her if that is actually true. Then again, maybe she just felt like pissing you off because of the way you spoke to her the day before. Who knows?
Your comment regarding the nurse calling about Coumadin with an INR of 2.3. Well, I've called in an INR of 4.6 and the primary doctor (who circled it in his progress note) saying "Go ahead and give tonight's dose of 7.5 mg." Ummm, don't think so buddy. You come in & give it if you want your patient to have it, but I'm not administering it.
ReplyDeleteAgain, the hospital limits us on "critical thinking." Personally, I would have just preferred to click "not given" & reason why instead of calling a doctor to get an order to hold it...but administration insists doctors be aware of everything to do with their patients.
We probably have a ton of examples on both sides of the spectrum....unfortunately common sense isn't so common...especially in a hospital setting.
I've since switched hospitals and while the calling critical lab values policy is the same, most doctors here have a physician's assistant or nurse practitioner handing their calls from 7pm-7am. Works for me...they are far less cranky. :)
Maybe nurses are so busy cleaning up their patient's, charting, talking to families trying to explain everything that SHOULD have been explained already by the 5 minute conversation with the MD, WE DON'T HAVE TIME TO CRITICALLY THINK. Sorry it's easy to become a great critical thinker when you're an MD with 4 years of advanced medical education and 2+ years of residency compared to my lowly 2 year nursing degree and you're right about the quality of education nowadays. But get off your high horse. You guys can't even write legibly for the most part yet you can bitch and complain all day about what nurses don't do and how much they bother you. And you're right most of the good nurses are leaving the profession.......ME INCLUDED! Nursing sucks! But doctors are Assholes for the most part!
ReplyDeleteHere's an idea...STOP ORDERING THE SAME STUPID
ReplyDeleteLAB THAT YOU DON'T WANT TO BE CALLED ABOUT!!!
Jeez..talk about your critical thinking...
At my hospital if we don't report a critical value within 30 minutes of receiving the value, we get written up. It has less to do with critical thinking and more to do with policy. Trust me, we know it's stupid AND we know how to think critically. We also value our jobs. Get over it...you're the one making six figures while we run around doing the dirty work.
ReplyDeleteThis is an old blog, but since I just found it, I have to put my two cents in.
ReplyDeleteFirst, JACHO has made critical labs a priority for the last two or three years to improve care. That means, that stupid rules were made by some government official without a clue. These rules are robbing nurses of critical thinking skills (those that have them, because yes, there are some just plain stupid nurses out there, but I have worked with some doctors just as stupid.).
Did you know that no longer can we accept a range pain med order (1-2 pills every 4-6 hours) because if I chose 2 rather than 1 I am making a judgement call, that the government says I am not qualified to make. If we treated the critical lab value yesterday, and it's better but still critical today, then the treatment is working right? But still, we have to call. (I wait until after 6 am, I work nights). Why that's stupid, but hey, these nurses are right, we don't have a choice anymore. I work in a hospital that supports physicians, and not nurses, so when the doctor's complain, we also get in trouble. There is no winning. Don't call, and your in trouble, call and he complains, your in trouble. We even have one doctor who has decided we call too much, and we have to have the house supervisor's permission to call him. Fact number one, physician NEVER answers until you have page him 2-3 times. Fact number two, the last night that instigated the change. It was two hours apart, different patients, but we are supposed to know that we will need him an hour from now. Fact number three, if a patient complains of pain, and I do nothing, I will get written up, but you better not call him. It's sad when I have to call a specialist, because the primary doesn't want to deal with his patient. It all started after his son died, but honestly, if he doesn't care, he should just retire. Not all nurses are stupid, but we sure have had to follow some stupid rules in the last few years.