Shhhhhhh…..
I don’t normally share the deepest secrets of my trade with just anybody.
But you? you are special!
pull up a chair and listen closely….. I will reveal to you a mystery of life which will change your destiny….. if you can handle it….. after this your nursing school trajectory will be brighter and happier….. and while you are at it, subscribe to this blog. At the bottom, you can click on a “Share” button to help your friends. Don’t you want them to do well too?
The back cover of my book. If this were a bookstore, you would read the back of the book-decide to buy. Find this on Amazon at https://goo.gl/PGTW30
Oh, and buy my book. It’s a novel I wrote to convey what it is like to work overseas in a missionary hospital. It’s not a sugarcoated version – the medical details are extremely accurate and well researched. It’s not the usual textbook but some schools have added it to the Global Health reading list. There is a love story of course!
Skills are more than psychomotor by nature
Okay, so I teach beginner nurses how to be a nurse. We start with well-meaning intelligent kids and turn them into professional persons. When people think about the skills nurses need to have, they list things such as giving a shot or doing a dressing change. Using sterile technique and doing the Five Rights of medication administration. Close your eyes and picture a nurse at work, and this is the image that comes to mind. These are the psychomotor skills, hands-on things we do for people.
It’s just as important to learn how to juggle time, set priorities and estimate workload, but these are “soft skills” – and a behavioral scientist might argue that since these can’t be demonstrated, they do not exist….. now – an educational paradox exists.
The Road Map to Success
The key to learning these skills is to learn how to use a Nurse’s Brain, what I also call a road map, and to incorporate it into your daily life. If you are not now doing this, it will be the biggest single revelation of your trip through nursing school.
Simplest version of instructions
This is part of teaching a new nurse how to prepare. Depending on your curriculum, the faculty will tell you ” go to the hospital the day before and learn about your patient.” A less experienced faculty member might leave it at that, and set you loose. Nobody tells you how much is “enough,” but a less experienced faculty will reserve the right to criticize you when you didn’t do it right.
Long ago I learned that beginners need to be shown how to prepare and given a specific description of what this entails. Effective prep is a skill in and of itself. Here goes.
Here is how to prepare
You will read the chart for all kinds of things – the diagnosis, allergies, meds, etc. your school will give you a template as to things you are looking for. look up each med the person is receiving. that sort of thing.
BUT, in addition to this – when you read the chart, you find the specific list of interventions and activities for the day. they will be always be somewhere, in the old days it would be found in the “Kardex”.
Six Steps to actualize it into reality and answer the question “what do nurses do all day?”
1) Start with the “Doctor’s Orders” (which aren’t really “orders,” we just call them that…we carry them out but that is not done blindly) a typical list goes like this:
allergies: none known
diet: NPO
v.s. q 4 h
activity OOB to chair TID
midline w > d dressing to abdominal wound q 8 h
I & O
foley catheter to bedside drainage
veno-dyne boots to LEs while in bed
pain med PRN
IV D 5 NS at 125/hr
that sort of thing. okay, this was simple enough. your job is to make it happen
2) The next step is to assign a specific time to each activity. so you make a piece of paper that looks like this:
0700
0730
0800
0830
0900
0930
10 00
1030
1100
1130
you can make a template for this, and there are lots of examples of sample Brains out there….
3) next, take all the items on the first list, and add them to the second:
0700 – nurses report, find out who the nurse is.
0730 – take vital signs, ask about pain, assess dressing, check venodyne boots and IV site, look at catheter
0800 – mouth care ( since he is NPO),
0830
0900 – ask about pain med again,
0930 -dressing change
10 00 – get OOB to chair, check I & O,
1030
1100
1130 – take vital signs again (it’s four hours since the ones you took this morning)
4) next, go through the list again, and add stuff that is assumed to be needed, according to the routine of the unit
0700 – attend nurses report, find name of staff nurse also covering your patient
0730 – take vital signs, ask about pain, assess dressing, check venodyne boots and IV site, look at catheter
0800 -look at IV site q 1 h
0830 – bathe patient
0900 – ask about pain med again, -look at IV site q 1 h, give 0900 meds if any
0930 -dressing change, ask about pain if the patient got some med in advance
10 00 – get OOB to chair, check I & O, -look at IV site q 1 h
1030
1100 – write DAR note in patient chart, complete ADL checklist
1130 – take vital signs again (it’s four hours since the ones you took this morning), report off to staff nurse
0700 – attend nurses report, find name of staff nurse also covering your patient
5) next, add some details that might not be obvious. put a box next to each item so that you can check it off when it is done.
0700 – attend nurses report ___,
find name of staff nurse also covering your patient ___________
read specific instructions for dressing change and check to see if supplies are in the room _____________
0730 – take vital signs, ______________
and report to staff nurse,____________
ask about pain,______________
assess dressing, _____________
check venodyne boots _________________
and IV site, ______________
look at catheter, ______________
check sacrum and heels,____________
reposition if needed,___________
listen to Bowel sounds____________
and lungs______________.
confirm that ID band is in place________________ (so you will save time later when giving meds).
check call bell and make sure patient knows where it is ___________
0800 -look at IV site q 1 h ______
assess mouth and do oral care ________________
see if any other students need help with turning their patient or incontinence care _____________
doctor’s rounds _____________
0830 – bathe patient ______,
do cath care ___________
complete head-to-toe assessment sheet from School for care plan.___________
ask patient about discharge plan, _______________
assess need for teaching _____________
leave bed in low position after bath __________
0845 – short coffee break _________
report to nurse that you will be leaving for fifteen minutes _____________
check to see doctor’s orders if any new ones were written ___________ check lab results for today _______________
0900 – ask about pain med again, _________________-
look at IV site q 1 h, _____________
give 0900 meds if any. ____________
make sure you took B/P _________before giving meds. ___________
decide what the theme of the DAR note will be. _________________
0930 -dressing change,____________ (follow recipe) ask about pain if the patient got some med in advance,
10 00 – get OOB to chair,_______________
check I & O,_____________
-look at IV site q 1 h_____________
1030 –
1100 – write DAR note in patient chart___________,
complete ADL checklist ___________
1130 – take vital signs again (it’s four hours since the ones you took this morning), ____________________
report off to staff nurse _________________
This is the short version. When I first teach people to do this, they may have up to forty items on the list, because they need reminders of everything. As you can see, the Brain evolves as you add things to it. doing a dressing is more than just doing the dressing – it’s checking the pain med, checking the order, gathering supplies, and negotiating a time. each of these gets their own spot on the checklist.
If your whole clinical group is using something like this, you can plan your work as a team; you can make time to help others; and you learn to share a language as to when each team member needs help or not.
6) During the time at clinical:
http://www.amazon.com/Sacrament-Goddess-Joe-Niemczura/dp/1632100029/the Nurses Brain goes on a clipboard, and you refer to it every fifteen minutes. cross off each item as you do it. at 0900, every item that was assigned a time before 0855 ought to be done. If not, you now know which are the priority items. when something happens during the day, such as a med not in the drawer when you go to get it, you make a note to yourself using this sheet, to recheck later. assign a specific time to every event. which specific time doesn’t matter as long as there is one!
Florence Nightingale herself once said that for a nurse, learning to use pencil and paper was far more important than learning to use a stethoscope. Okay well, we’ll teach you the stethoscope too, but this Brain is what the pencil and paper are for!
There is an old rule that if you get your stuff done, and become known as a person who always completes their tasks, you will be rewarded by being assigned more tasks the next time. You can not possibly achieve this state of bliss unless you use a checklist. The staff nurses always make snap judgements regarding the students – if you prove to them that you are using this, they will be positively impressed. They hate it when you fail to do something and then also fail to communicate with them. If you’re not going to be able to do something, you can use this tool to estimate what that would be and then tell the staff nurse in advance, which will safeguard the patient from problems. We are all part of the team!
Using your brain is a key to college – using the Nurses Brain is the key to successful nursing!
tomorrow: part two: checklist culture and your role in quality. There is a lot of attention being paid to this issue, and if you are the kind of nurse who makes “to-do” lists, you will succeed in nursing and in life.
don’t miss this next one! subscribe to this blog now!
Nursing in Hawaii 
Ahhhh yes, the Nurse Brain…I know it well. I have been a nurse for 26 years and in that 26 years, I became a mom and studied (but did not gain certification in) Hospital Chaplaincy. In my work with grieving parents, I listen with Chaplain’s ears, think with a Nurse’s brain and speak with a Mother’s mouth. I can be looking right at someone with peaceful, patient appearing visage, but my brain is buzzing as I assess everything in the environment to figure out where the freight train is coming from, when it will hit us and how I can stop it.
thank you for this. I will be writing part two within a day or so – but here is a preview.
a paradox:
nursing is more than just the tasks, as you so poetically describe. ( and yes, the nursing profession can be proud of counting people such as you among it’s members!)
but
without getting the tasks done, oftentimes we can not move to the truly important stuff ( which is always the psychosocial support such as you describe).
and yes, the Brain ( or Road Map) has room to include a written reminder to yourself to deal with psychosocial issues……
more to come ( going to church this A.M.)
These are all excellent points and my experience of nursing school confirms what you imply — that the essential skill of time/task management is indeed not taught. Instead, nurses learn it the hard way — on the job — and when they share this wisdom (as you do in your blog) it is informally, not as a hospital “best practice” nor as a systematized skill. Let’s change all that!
You also mention the Checklist Manifesto. Let’s do for nursing what Atul Gawande (the Manifesto’s author) is doing for surgeons. Error rates go down and quality goes up. Stress (due to cognitive load, i.e. so much to remember!) goes down and patient safety goes up. Everybody wins.
Kudos to you!
Part two will address the Checklist Manifesto. Or maybe there will be a part three!
THANK YOU for this validation. PLease pass this along to everyone you can think of…… let’s take this viral!
We can all use the tools of a Road Map. Too often the feedback system is re-active as opposed to pro-active…..
Well, this is exactly what I’m working on — see http://www.nursesgetitdone.com
You will especially enjoy the Brain Museum (link in upper left corner).
If you have any Brains you’d like to share, please send ’em and I’ll add ’em to the collection.
They are most interesting when they are marked up (used) rather than blank.
Of course, erase any HIPAA (PHI) data!
We are both looking at/thinking about/working on a big gap in formal nursing practice —
very interesting! Thanks for sharing your insights!
I added the link to my blogroll.
I agree, the idea is to see examples of how somebody else does a “brain” – that is what is illuminating.
The cognitive work to set this up uses the same system of logical thinking that serves as the basis for informatics. I like how you set up the idea of using a iPhone to achieve the same goal. I am always amazed at the way the Youth of Today use technology with such facility…..
True that task management is a basic nursing skill but nurses need to be so much more than that. After 28 years in ICU the question I teach new nurses to ask and ask again is “What is really going on with my patient?” anyone can be taught repetitive task management and we all need those skills. You are not a real nurse until you can ask and answer the “what’s up here” question and ask the all important, followup question, ” What does my patient need right now to avert a crisis?”
I agree wholeheartedly, but the skills have to be there. This blog is directed at new nurses who have yet to figure this out. If I were to look at whatever Nurse’s Brain you may or may not have, I am certain it would look very different than the examples I am giving here – but in no way does it imply that you aren’t also doing the basics. If the student nurse is new, don’t assume that they know how to organize their day, and don’t leave it up to chance. Put it on the table and teach them. That’s my message here.
Really its useful task for us. Doing the things in a creative way everyone loves it..!!
I am not the inventor of this system, I just help others use it. Please share the link as widely as you can, and encorage others to organize their work this way. Also, why not subscribe to my blog and buy my book? :-)
Joe
Reblogged this on bonenurse.
I still use the original road map you outline for us (Updated) versus the simplified versions suggested since then. I find it is much more effective using the manner you described and taught above as a student nurse to ensure I do the “little stuff” that may be obvious to an experienced nurse but I feel can get lost to me as a student when I get overwhelmed with more complex tasks
for example, i always have my hourly safety check on there with check urinal or hat next to it and have “make sure room is neat and tidy” as one of my first and last checks which I believe you emphasized as well because of the thinking: if the family were to show up would their family member look cared for?
The above you describe/taught works better for me then anything else taught and I often wonder how my other classmates who gather all of the information on their care sheet but don’t render it into a useful plan via the brain organize it all in their head.. especially now with multiple “heavy” patients…
….but you left out the part in the organization where the brain should be crumpled up and have coffee stains on them !!
Yes, there is one surefire way to convince the family that we actually care about the person and care for them: it is to *do the work* – there is no substitute.
And the best laid-out plans will never help unless they are put into play. I think the beverage of choice for the youth of today is a smoothie though
Joe, Smoothies are definately healthier then those speed drinks that are sooooooo hight in sugar, and will in the end cause fine hand tremors.
Half of me agrees with you a hundred percent
;-)
I assume you refer to Red Bull or some such. I think those drinks ought to be banned. Yes, I myself am “old school” – a charter member of The Coffee Achievers Club. But I never put sugar in it, and it’s gotta be Starbucks. I could easily sign on as a spokesperson for that company (disclosure: I do not own stock in them or profit in any case from this endorsement). In Nepal I found all the places to get “Lassi” – the prototype for smoothies; these are better than ice cream IMHO.
Yeah, I once tasted what they called “ice cream” in Brazil, which tasted more like soap to me.
Laurel sounds like a nurse I would love to work with. There is nothing that grinds my teeth worse than a nurse sitting at the desk at nine o clock texting, while her/his patient rooms look a mess. (Speaking as a charge nurse, anyone caught texting gets a new admit because that’s a nurse who need something to do.) Joe, I do like your brain and it looks like a good way to teach students. However, we have a ten minute overview report followed by bedside report, then it is go go go. Do you have a preprinted template your new nurses can just fill in? I’m not sure when a floor nurse would have time to make a detailed outline for the day.
I l*o*v*e the way you determine who gets the admits – that made me chuckle with delight – it’s the kind of thing I would do. I tell my students that I personally will not be sitting down at anytime except for coffee break and while in the bathroom, and a secret of my ability to instill teamwork is that I am good at finding things to do when there is just five minutes of downtime for an individual at clinical. My groups are never bored at clinical and I emphasize teamwork.
Maybe I should make a blog #4 for this to reveal this next little trick, but – since you mention it.
The nurse-to-nurse report thing could be handled several ways. First, what is the degree of computerization at your place? the new infomatics systems often supply a per-patient printout that substitutes for a “brain” and you may be able to arrange with your infomaticist (is that even a real word?) to create a space on each form for the kind of nursing items we discuss here.
in the 1980s I was nurse-manager of an ICU/CCU where all the nurses used a brain, and they had a twist to it (adopted before my arrival) in which one of the duties of the offgoing nurse was to construct a nurse’s brain for the next nurse. obviously it would be subject to change, but it was a good way to start. it had a summary of labs, IVs, treatments, etc when the system worked (most of the time) it was terrific. you might consider this. it’s way to get the staff involved into the subject of what we nowadays refer to as “handoffs” and accountability.
and yes, going back to an earlier post, there is more to this than simply the tasks.
finally, Lauren is exactly the kind of nurse you would want to hire. she graduates in another year or two and I will happily send her your way!
Joe
Ahh, here we are, back to my favorite topics: brains, handoffs, time management, data sharing. We’re making great progress on these issues! Lots of info on my blog at http://www.nursemind.com (yes, we’re finally changing the name to nursemind.com — people thought nursesgetitdone.com was a porn site! :-)
We’re scouting for a couple more good sites for beta testing.
A nursing school’s clinicals group would be a good one. This would:
a) help the clinical instructor make sure the students understand exactly what’s expected of them and when
b) reduce students’ stress by helping them be confident they’re doing the right things and forgetting nothing
c) help the clinical instructor (with a real-time “control panel”) see who is where, and whether anyone is falling behind… I remember how stretched thin my own clinical instructors were. They would have loved this.
Anyway, think it over. Let me know if you’re interested or just want to talk.
Dan
dan@nursemind.com
i already use this – that’s the point. you are preaching to the choir to ask me.
I agee that all nursing faculty need to teach their students to use this system in some way or other.
BTW I tried your new link and it didn’t not seem fully operationalized….. let me know when it gets done….I will happily change the URL on my blogroll.
You already use it? You are a magical nurse indeed… The product is not yet released! But you could indeed be a beta site — shall we discuss it? And work together to change nursing forever?
(Sorry about the web site… try this URL: http://www.nursesgetitdone.com/
Thanks,
Dan
LOL – yes of course I am a magical nurse – I have a Master’s Degree! But, re-reading this thread, I am confused. Any nurse that finds my blog would do well to go to your site; but if you are tryin g to promote a specific “thing” – (computer program? PDA? Thought process?) You might consider getting a lot more specific as to the plan. It was clear to me as to what you were trying to say.
And for me personally, I already have a system I teach, which is how you found the blog entry in the first place. :-D
thanks alot
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