Critical Thinking & Delegation

What to do? This happened one day when I was working as the shift supervisor at a metro Detroit hospital… An elderly patient with COPD was very anxious- she was restless, could not get comfortable and kept fidgeting in the bed. The RN called the physician and obtained an order for ativan to help her settle down. The patient went into respiratory arrest shortly afterward and almost died

What happened?? The elderly patient had COPD, and her restlessness was due to hypoxia, not “nerves” When the RN obtained the order for the ativan, the respiratory depressant effects of the drug further impaired the patient’s breathing until she went into cardiac arrest The patient was intubated, placed on a ventilator, and sent to the ICU where she survived the incident

So why learn about critical thinking? Nurses need to make critical decisions all the time Nurses are the ones with the patients all day and night, unlike doctors who usually only spend a few minutes with patients (sometimes from the doorway) Nurses are the ones who are most likely to pick up on slight changes in patient conditions and then decide what to do… Who to call?Call the doctor? Watch & wait?What to do first?

Critical thinking Not having the answer but being able to intelligently think through the problem Ability to consider a variety different causes and solutions for a given problem Knowing when and where to look for help with a problem “Next to the possession of knowledge itself is the ability to turn where knowledge can be found”

Critical thinking If you ask 12 RNs what critical thinking is, you will probably get 12 different answers But RNs will all agree: Nursing is much more than just passing meds and leaving stuff for the next shift Judgment calls are a very important part of nursing practice The biggest threat to critical thinking is just focusing on tasks to be done and not thinking about what you are doing and why

So that means… If the RN in the incident above had used critical thinking skills, she might have realized that… The patient’s anxiety and restlessness might have been due to something other than “nerves”… A thorough physical assessment might reveal other causes of the patient’s distress… Other causes of anxiety should be ruled out before obtaining a sedative order for an elderly patient with COPD.

Assumptions Part of critical thinking is being aware of assumptions and working to make sure that they aren’t flawed For instance… I decided not to assume that my patient who had been admitted with a drug overdose didn’t have any more drugs in her belongings that were brought with her from the ER Thank goodness I checked- I found some Xanax, some Tylenol and some other white pills! My patient could have taken these when nursing staff were not in the room!

Assumptions Another for instance- I was charting at the nurses’ station and I heard the water running for a long time in a room near where I was sitting I became curious, and I went to check… A patient (not mine) was at the sink trying to stop the bleeding from where he had pulled his IV site out. He was very unsteady on his feet and should not have been out of bed If I hadn’t gotten up to check on the sound, he might have fallen on his way back to bed, especially with the blood that was on the floor

Critical thinking Successful organizations are staffed by people who think, not just follow orders The biggest threat to critical thinking is just focusing on tasks to be done or “putting out fires” and not thinking about what you are doing and why

Critical thinking is… Active, organized thought processes to analyze, draw conclusions, make decisions, and form inferences Taking nothing for granted Identifying and challenging assumptions Prioritizing Imagining and exploring alternatives Applying reason and logic

That goes for nursing students, too! A few years ago, an OU nursing student in clinical received report about a patient who had just undergone an angioplasty the night before The night nurse said that the patient was fine, and resting comfortably. But… The nursing student did her assessment and found that the patient had hemorrhaged from the angioplasty site during the night and had been vomiting! The nursing student notified the clinical instructor right away and worked with the patient’s day nurse to contact the doctor and send the patient to emergency surgery

Critical thinking & assessment Data collection is not an end in itself- it isn’t done just to get the forms filled out and assignments completed Assessments are done so that the findings can be analyzed and problems can be identified

Cognitive dissonance A fancy term for when you get that bad feeling in your gut when somebody tells you one thing but your gut tells you that something else is actually going on Sometimes you get a bad feeling about a patient’s condition even though the doctor says that the patient is just fine…

Intuition vs. physician I was working on a medical-surgical unit when a new patient was admitted from ER with a diagnosis of pancreatitis The young woman was clearly in shock- pale and lethargic, a 70/40 BP, and very cold extremities I was told that the patient’s doctor was aware of the patient’s condition, was not concerned, and wanted her admitted to the regular floor, not the ICU. Hmmm…. Who to believe? What to do?

Intuition vs. physician Regardless of whatever the doctor thought, I realized that this patient was in serious trouble I decided to call the house doctor to see the patient right away and offer her opinion of the situation She was extremely concerned about the patient, did a quick yet thorough assessment, and contacted the patient’s doctor herself It turned out that the patient’s attending doctor had not seen the patient himself, but had relied on the assessment findings of the ER doctor

Intuition vs. physician The patient was immediately transferred to the ICU, and the patient’s attending doctor came to see the patient there He was very upset at the ER doctor, who had neglected to order some lab tests that would have indicated the seriousness of her condition The ER doctor also thought that the patient was “faking it” when she first came to the ER, and didn’t monitor her condition as she progressed to shock.

Intuition vs. nurse The ER nurse noted that the patient was going into shock, and believed that the patient should have been admitted to the ICU, not to a medical floor However… instead of speaking to the doctor or notifying the nursing supervisor about it, she decided that “I’m just not going to talk to that doctor any more!” If you are ever in doubt about a patient’s condition or have concerns about a physician’s order, ask the charge nurse or clarify with the nursing supervisor!

Autonomy Patients have the right to self-determination That means that they have the right to decide for themselves about their health and treatment options Patients have the right to refuse treatment or medication even if they may die without it If the patient is a minor, parents are expected to make these decisions If an adult patient is unable to make decisions for himself, decisions are made by the family members or a court- appointed legal guardian

Delegation RNs may delegate tasks to other members of the health care team Licensed practical nurses (LPNs) Nursing assistants (NAs) Do not delegate tasks that require nursing assessment or judgment Formulating nursing diagnoses Notifying doctors of changes in a patient’s condition Changing plan of care for a patient Advanced nursing procedures & interventions

Delegation So what might you delegate? Bed baths and bedpans Changing incontinent patients Feeding patients Taking vital signs Walking patients in the hall Getting patient up in the chair Making beds Bringing ice water to patients

But there’s a catch… You have to use your nursing judgment to know if a particular tasks should be delegated! For instance… Your elderly patient just had a stroke and has difficulty swallowing. Since there is a good chance that the patient might choke on his food, it would not be a good idea to have the nursing assistant feed this patient If your patient is very unstable (going into shock, perhaps!) you would want to take the vital signs yourself to make sure that they are accurate

Delegation Make sure that the task is OK to be delegated at that particular health care facility… Some hospitals allow NAs to give enemas, while other hospitals do not Some hospitals allow NAs to check patients’ blood sugar (with a bedside monitor) Some hospitals allow LPNs to do admission assessments for patients with a co-signature from the RN Other hospitals require the RN to do admission assessments

Delegation Make sure that the staff member knows how to do the task correctly! If the NA or LPN makes a mistake or does not perform the task, the RN is responsible for the error The RN must go back to make sure that the task was completed Do not delegate tasks that you are unwilling to do- This creates hard feelings with the staff- very bad!

Delegation You must work nicely with others! For instance: If you are in a room and the patient asks for a bedpan or a pitcher of ice water, don’t spend 15 minutes hunting down a NA to do it…do it yourself right then. This will foster a good relationship with the patient (who recognizes that you will meet his needs right away) This will foster a good relationship with the staff (who won’t feel like you are dumping on them)

Delegation When LPNs or NAs do a great job on a task that you have delegated to them, let them know! Be sure to thank the LPNs and NAs for their hard work- it makes them feel appreciated and respected. It is important to keep a good working relationship with assistive personnel- when you help them out, they will be more willing to help you out

When delegation doesn’t work out… If you are unhappy with the work that an LPN or NA has done: Pull the NA or LPN aside privately- do not say anything in front of a patient! Be constructive and appropriate feedback, and be specific about your expectations for the task. You may need to review the correct procedure for the task- sometimes the problem is due to lack of knowledge, not lack of trying