“If we try to teach critical thinking by only teaching, focusing and drilling the TASKS, it can often seem overwhelming and unachievable in the direct moment. If we present it from the top (the situation) down to the details, we can SHOW the path we are walking - and they will be able to follow.” - Audrey Friedman, RN

[Original post: 10/28/2014] As a preceptor to new nurses and nurses new to our units, there is a lot to teach, isn’t there?  Regulations, Unit Based Information, Skills, Knowledge, People, Resources and basically, the most important one… where to find stuff.

In orientation, I think the hardest part of teaching is helping nurses learn to put all the pieces together. 

For my own creative purposes, I call each patient case a “pie”.  Some have lots of slices:  history, cause of admission, labs, tests, procedures, medications, family, etc.  You get the idea. 

My favorite type of pie is caramel pecan silk from Village Inn [… sigh…] and my favorite type of patient cases is sepsis.  Each of the units you work on have their own specific challenges as well.

Each of these challenging case types have multiple layers of information, interventions and critical thinking that are required.  Like the graham cracker crust, filling, and toppings.  Taking each specific item separately can be overwhelming to a new nurse in your unit.  Depending on their amount of experience, they may only see 25% of what you are seeing.  They stand in amazement of the creation you have made!

In the ICU, we frequently use IV drip medications for a lot of our cases.  They can vary between sedation, vasopressors, vasodilators, paralytics and narcotic pain medications.  In critical patients, you can often have multiple drips going at the same time.  I think my highest number was 9.  Yes… 9 drips for my vented patient.  A combination of sedatives, pain medication, vasopressors and cardiac medications.  I am sure some of you have even had more. 

I did an impromptu bedside case presentation and education spot for some of the new nurses about this very interesting case of 9 drips.  When they walked in the room their eyes all bugged out with the 3 double IV poles and the 9 pumps going.  You could palpate the tachycardia that was going around the room.  Questions were being thrown out nervously… How do you know which one to titrate?  How fast to you titrate them?  How do you know which one is working?  All fantastic questions!!!

I gave them a little time to reboot their heads and then I stood in front of the pumps to block them as I started the presentation, slowly moving away to let them see the pumps as I explained the situation, the problem, and finally… the reason for each drip and how they were being used.

But each one of them was initially blindsided by the ‘task’ of the 9 pumps and drips and had to take some distraction [me in front of the pumps] and some redirection back to the situation, the problems and the rationale for the drips before they could put the pieces of the ‘pie’ together. 

If we try to teach critical thinking about critical patient situations and the required medications by ONLY teaching, focusing and drilling the TASKS, ie about the medications, it can often seem overwhelming and unachievable in the direct moment, to be able to put the pie together for a new nurse.  It is a lot to learn. If we present it from the top (the situation) down to the details, we can SHOW the path we are walking - and they will be able to follow.

So, once we took the case apart… started from the top down… ending at each drug, their rationale, priority of titrating, evaluation of success... they started to breathe. 

They were even having some fun as I started throwing out some clinical scenario questions about which drug they would titrate or change if something specific happened.

AND HERE IS WHERE I ALWAYS START… I ALWAYS START AT THE TOP… WHAT IS OUR SITUATION?   And even if they don’t know the details, they know it is one of 3 phases:  EMERGENCY, CRISIS or STABILIZATION.

Great!  That tells me A LOT OF INFORMATION!  Each phase can tell you what the situation is, the potential situations that can happen; what goal you are trying to achieve and, the basics of how you want to use your drip medication. 

1.        EMERGENCY:  examples:  CODES, emergency procedures, unstable patients, unstable post-operative patients

The GOAL is:  to perfuse organs quickly.  To prevent death.

The SITUATION is:  any emergency situation that is rapidly decompensating and has the potential to cause death.

The PROCEDURE of using drips can include titrating the drips quickly, sometimes jumping to the tip of the parameter in order to achieve the desired parameters [often vital signs, pulse and perfusion].

2.        CRISIS:  examples:  hypertensive crisis, seizures, sepsis

The GOAL is to stabilize situations and prevent emergencies or decompensation of the situation.

The SITUATION is any situation that is or can become unstable and potentially cause another unstable event.  Requires frequent assessments and close observation.

The PROCEDURE is to titrate drips with standard medication recommendations to achieve the ordered parameters [vital signs or clinical signs]. 

3.       STABILIZATION:  examples:  stabilizing sepsis, bleeding, respiratory or cardiac arrest

The GOAL is to continue the recovery without rebounding to an unstable situation.

The SITUATION is any situation that is past the initial unstable event.  Becoming stable but not ready to discontinue treatment.  Requires frequent assessments and close observation.

The PROCEDURE is to titrate drips slowly to wean medications off.  Titrating too fast may cause a rebound effect.  You may reach titrating plateaus where you are unable to wean further for a time.  This means the patient is healing, but the situation is not completely over and the patient continues to require the medication.

So, even as my Orientees, or even experienced nurses that come to me with questions about drips, titrating, clinical questions… I start with the question at the TOP… WHAT IS OUR SITUATION?  WHICH OF THE 3 PHASES ARE WE DEALING WITH? 

From there… we IMMEDIATELY know our GOALS, the SITUATION, and the PROCEDURE for titrating drips… fast, moderate or slow.  And we quickly gain the overview perspective of the direction we want to go in our case. 

THE NEXT SUPPORTIVE STEP is learning the medications themselves.  This is critical if nurses are going to make knowledgeable, care-directed and appropriate decisions.  And yes… I have homework for that too!

Try starting your learning and teaching with this downloadable handout… The NWW CLINICAL CHALLENGE:  3 STEPS TO IV DRIPS.  Try it out yourself, and with some of your nurses.

Click here for The NWW Clinical Challenge: 3 Steps to IV Drips

And MOST IMPORTANTLY… Consider adapting this tool to your specific clinical area.  The idea is good for all kinds of clinical units, not just ICU.  I know if you take a moment, you can think of how to describe and address the 3 Situations for your clinical area.

If you would like help, please let me know.  I would be happy to help you.  Hmmm… I see something good to use for ‘The Preceptor Project’!  Wait… I just gave myself homework!

Let me know what you think of the tool!  I look forward to your feedback and stories!

Inspire and Be Inspired, Nightingales!

Audrey Friedman, RN