Tag Archives: priority setting in nursing

part 2: The Nurses “Brain” – how to bring your “A Game” to clinical

read part one first. That was among my most popular entries ever. If you are finding this useful, your fellow students probably will too – why not share it with them? It’s part of a series of blogs on the current nursing scene, especially for new nurses and nursing students. I also invite you to  subscribe!

“What we Have here, is a failure to communicate…..”

There are a few common scenarios in nursing education. These take place at clinical.

a) at the end of the clinical day the instructor is making rounds after the students have left, and one staff nurse says “your student in rm 438 did not give a bath, did not report the vital signs, and omitted a med that was due at noon” (this always puts the faculty on the defensive, in case you wanna know)

b) the teacher and the student are lined up at the med cart about to give a heart pill, and the student did not check the Apical Pulse or take the Blood Pressure. Or maybe it’s a stool softener and the student has no idea when the last time the patient moved their bowels. or maybe it’s lasix and the student doesn’t know what the K+ was.

c) the student takes report from the night nurse, but doesn’t write anything down and can’t recall what was said when the faculty asks what the night nurse had to say about the patient.

I can think of more; but what I want you to ask yourself right now is, have any of them happened to you?

The reaction to all of the above, is to pass the feedback along to the student, and maybe to put the student on a written warning, which is logical. After all, we’re about doing our best, here. If the student gets enough written warnings, they learn to be afraid of making a mistake, (which is good); but they also learn to dislike clinical, (which is bad. clinical is the reason we are here). And the faculty wonders why this happens over and over again…….  a new faculty person is also on a learning curve, and when you are new at teaching, y0u may not have the tools to develop a better approach. It’s easy to blame the students….

Pro-Active? or Re-Active?

Simply dumping on the student is usually a sign of a faculty member who did not see the value of teaching organizational skills to their crew. It’s the easy way out – a way for the faculty to shift blame. It’s Re-active – closing the barn door after the horse has left. Both the student and the faculty will benefit from a pro-active approach – oh, and so will the patient :-)

You may find this difficult to believe, but to use a Road Map, also known as the Nurses Brain, is a pro-active tool in preventing all of these things from occurring. There is no situation so chaotic that a Brain can’t bring some order when it is applied.

Part One dealt with how to set up a Brain.

I got a terrific reply to Part One  from Dan Keller, a nurse who has a Blog Site Titled Nurses Get it Done. Dan was very humble about his site, but I was happy to find it. Go there, and you can find more examples of a Nurse’s Brain. He also has info about an iPhone app that can be used to keep track of all the little pile of details that a nurse has to deal with.

So – how to become pro-active vs Re-active?

For me as a faculty, I require that the student bring a Road Map to clinical and show it at the beginning of the clinical day. Every time I speak with that student during the day, we pull it out and go over it. Every time a staff nurse gives report, the student also writes down every tidbit of data that has been shared, and the student has to determine whether a followup response is required.

I got another email from a nurse who said she wants to make sure the student can name what’s going on with their patient “and that’s the most important.”  Fair enough. She probably works with seniors; and also,  when you make a Road Map every day, you can add reminders to yourself to schedule an actual time to physically assess the most important feautures of your patient’s illness event. In addition to the Road Map, we also require a Concept Map, an eight-column medication form etc – if I made it sound like we didn’t, or that I never bring up the more sophisticated concepts of patho, don’t worry – we do those things.  The time to start using a Brain is Fundamentals – from the beginning of hospital practice.

Accountability

One of the mantras is: ” we don’t have to do every single thing we planned out for the Road Map, but if we can’t, our responsibility is to tell the staff nurse with sufficient time so that they can do it before it’s too late”

If the whole crew is using a road map, it allows the clinical groups to create synergy, and help each other by scheduling some tasks for the larger group – such as doing incontinence care for a 400-lb helpless patient, for example, which would require more than just one person. I worked at a 400-bed hospital in Bangor, Maine, where the nursing crew routinely delivered care for  patients with life-threatening morbid obesity – that group of nurses were a marvel of teamwork. This eliminates a lot of mini-crisis from the day.

Buying the morning paper?

The next thing that can happen with a well-planned Road Map is effective chaining of tasks. Now, women are much better at chaining tasks than guys are ( hate to sound sexist and I don’t know why this is the case, but I think it’s true). True story: if I was going to get the morning paper from the corner store, I would go and get it. But, if I mentioned to  my wife I was going down the street for that purpose,  she would say “Oh, and we also need toilet paper and would you get some bread and milk too?”  My wife was also a nurse. Nurses become excellent at “chaining” tasks.

Chaining….

an example of chaining for the Road Map would take place after you observed that it was an hour after breakfast and  your patient was incontinent of stool.  Obviously, you are going to help them with personal hygiene; so you might as well do their whole bath at that time, and you will bring in the supplies to do a sacral dressing change if they have a sacral wound, and you can also check their heels at the same time, do range-of-motion and repositionthem. six tasks with just one trip into the room.

The Checklist Manifesto

We are on a quest for excellence in nursing, not just personal excellence but excellent patient outcomes in team care. And I can’t speak highly enough of the books by Atul Gawande, MD.   His book, the Checklist Manifesto, is about the ways that teams improve, and he has lots of practical examples and a great way to express how to approach the idea of improving your practice day-to-day.

I can’t really add much beyond what the reviews have already said, but here is a start, from Amazon.

Amazon Exclusive: Malcolm Gladwell Reviews The Checklist Manifesto
Malcolm Gladwell was named one of TIME magazine’s 100 Most Influential People of 2005. He is most recently the author of What the Dog Saw (a collection of his writing from The New Yorker) as well as the New York Times bestsellers Outliers, The Tipping Point, and Blink. Read his exclusive Amazon guest review of The Checklist Manifesto:

Over the past decade, through his writing in The New Yorker magazine and his books Complications and Better, Atul Gawande has made a name for himself as a writer of exquisitely crafted meditations on the problems and challenges of modern medicine. His latest book, The Checklist Manifesto, begins on familiar ground, with his experiences as a surgeon. But before long it becomes clear that he is really interested in a problem that afflicts virtually every aspect of the modern world–and that is how professionals deal with the increasing complexity of their responsibilities. It has been years since I read a book so powerful and so thought-provoking.

Gawande begins by making a distinction between errors of ignorance (mistakes we make because we don’t know enough), and errors of ineptitude (mistakes we made because we don’t make proper use of what we know). Failure in the modern world, he writes, is really about the second of these errors, and he walks us through a series of examples from medicine showing how the routine tasks of surgeons have now become so incredibly complicated that mistakes of one kind or another are virtually inevitable: it’s just too easy for an otherwise competent doctor to miss a step, or forget to ask a key question or, in the stress and pressure of the moment, to fail to plan properly for every eventuality. Gawande then visits with pilots and the people who build skyscrapers and comes back with a solution. Experts need checklists–literally–written guides that walk them through the key steps in any complex procedure. In the last section of the book, Gawande shows how his research team has taken this idea, developed a safe surgery checklist, and applied it around the world, with staggering success.

The danger, in a review as short as this, is that it makes Gawande’s book seem narrow in focus or prosaic in its conclusions. It is neither. Gawande is a gorgeous writer and storyteller, and the aims of this book are ambitious. Gawande thinks that the modern world requires us to revisit what we mean by expertise: that experts need help, and that progress depends on experts having the humility to concede that they need help. –Malcolm Gladwell

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part 1: Secrets of a Nurse’s Brain – six steps to success at clinical practice, or anywhere!

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?

9781632100085-SOTG-Nepalt.indd

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!

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