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Ep213: What the HELL is Critical Thinking . . . and Why Should I Care?

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Why all the fuss about critical thinking?  How does critical thinking actually work on the floor?

This episodes uses real life examples to show you how critical thinking works on the floor and how it kicks in with nursing care plans. 

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What’s up, guys? John Haws, RN CCRN with NRSNG.com. Today I am really excited to bring you an episode in our series on critical thinking and nursing care plans. Before we get rolling into the episode, I want to let you guys know that if you go to NRSNG.com/criticalthinking … That’s NRSNG.com/criticalthinking, you will find a massive monster post on creating nursing care plans and how to apply critical thinking in nursing school. Now that’s something that nursing professors and nursing schools love to mention. They love to mention you need to be critical thinking, but they don’t ever really tell you how or how it applies. In this post, we’ve done that for you. That’s NRSNG.com/criticalthinking.

 

On that post, as well, there is a free download of a care plan template that you can download and just fill in. It has all the spots where you can just fill in exactly what you need to have a really effective, good nursing care plan. That’s NRSNG.com/criticalthinking. All right. Now let’s roll into this. This is another episode in our series on critical thinking and nursing care plans. I hope you guys enjoy.

 

What’s up, guys? Kati Kleber here, CCRN here. I’m going over this blog post I just wrote. Master post. I’m really excited about it. It’s called “Critical Thinking and Nursing Care Plans Go Together Like Chicken and Waffles.” Yes. Oh, have you had chicken and waffles? If you haven’t, press pause right now. Go get chicken and waffles. Eat it. Come back. We’ll talk. All right. Why? Why am I saying this? Okay. Fried chicken and waffles. They don’t seem like they go together, but you guys, they so do. So, so do. I think this is the same with critical thinking and care plans. I thought that in school especially and actually up until recently, thought they were really two totally different things, but they’re not. I promise you, they’re not.

 

Let me go through this and define and explain critical thinking, define and explain care plans. Then let’s put it together and see why they … You’ll see why they don’t seem like they go together, but we’ll see why they actually not only go together, but they go together well and compliment each other. Because you do these two successfully, you’re providing safer, better care to your patients.

 

All right. What is critical thinking? Isn’t that that term that you’re just like, “Okay, if they say critical thinking one more time, I’m going to lose my mind. What they heck do they mean by critical thinking? Of course I’m going to think about what I’m doing”? Critical thinking is actually something you’re going to do every single shift, every single shift as a practicing nurse. Not one day will go by in which you don’t look at a situation and critically think. Basically I’m going to just describe this process, but think about it like this. When you’re shooting a layup in basketball, when you learn how to do it, it feels very mechanical. Step one, dribble. Step two, do this. Step three, do that. It seems very mechanical at the beginning. As you do it more, as you get more used to it and as you get more comfortable with it, it becomes this fluid motion. It’s something you start to do without even thinking about it. You just do it when you need to. Someone doesn’t have to say, “Hey, go shoot a layup.” You can just do it.

 

Hopefully you can marry that in here. That’s the same thing. When you are critically thinking in school, it’s going to feel very mechanical and planned and not so natural, but it’ll get easy. It’ll get easier. Sometimes it’s not as easy as other times. Basically what you’re going to do, you’re going to recognize a problem or an issue. You recognize it. Then you’re going to determine what the best solution for that problem is. Then you’re going to determine, “Hey, was that intervention successful? Do I need to intervene again? Should this situation present itself later, will I do the same thing?”

 

Let me give you a very practical, practical example. There are more at the end of this. I’ll go through a couple more at the end, but let’s say a main problem. Sitting at the nurse’s station. I work on a regular med-surg nursing floor. Not ICU, not ED. Just regular old med-surg floor. My patient is on continuous pulse ox and a cardiac monitor. I see that my patient’s oxygen saturation is 82 percent. That’s low. I’ve got to deal with that. I run into the room and I see my patient scrunched down in bed. They’re supposed to be on a couple liters of oxygen and it’s of course laying on the bed and not in their nose. They’re breathing labored and they’re coughing a little bit. All right. I see a problem. I see a situation. Low oxygen saturation. I’ve got to get this oxygen saturation back up like three minutes ago. What am I going to do?

 

While I’m walking into the room, I’m going to go run and grab my … “Hey, hey. Can you come help me just real quick?” Go grab a coworker. Have them help me boost up my patient so they’re sitting upright. It’s a lot easier to breathe when you’re sitting upright than when you’re scrunched up. Sitting upright. While I’m doing that, I’m going to quickly apply their nasal cannula. Let’s say I hear them starting to cough and clear their throat. I’m going to grab the suction that could be connected to the wall and I’m going to suction out the sputum they cough up. All of a sudden I see their oxygen saturation back up. Beautiful. They’re sitting up. They’re breathing in and out. They got the gunk out of their throat. They’ve got their oxygen back on their nose. No more labored breathing. They’re not coughing. “Hey, when is lunch going to be here?”

 

That’s a very simple scenario, but that is critical thinking. First I recognize there is a problem. Then I decide on my intervention and then I decide if those interventions were successful. Woo-hoo! It worked. Thinking about it, it’s not something that you just do overnight. You don’t just read a textbook and know how to critically think and analyze situations and think about the best outcomes because you haven’t been in a lot yet. You haven’t seen a lot of patients in various situations and you don’t know the basic troubleshooting to do and how to escalate the troubleshooting and when to bring a person in the room and get another set of eyes. You don’t know that yet and it’s understandable. You haven’t had a lot of patient experiences and that’s okay.

 

The concept really gets introduced in nursing school, but you start to see it in action in clinicals. When you’re in clinicals and observing other nurses, they’ll be doing it all day. Honestly they’re going to be doing it without even realizing they’re doing it. It’s helpful to observe and ask. “Hey, I saw that when this patient hadn’t peed in awhile after their catheter was removed. What made you want to have them drink some more fluid and move around and do this? Why do you want to straight cath them? Why not put another Foley in?” Thinking about those kind of things. It takes practice. One of the things that you can do to practice is utilize that clinical time. Do this question game that you can do. You’re looking at a patient. Let’s say you’ve got a septic patient in front of you. You’re doing clinicals in an ICU and you’re just observing. I recommend doing things like … You probably have a lot of questions or just overwhelmed. You’re not sure where to start. Some ideas and questions to ask and ways to cultivate this critical thinking.

 

Let’s say I’m looking at a septic patient in an ICU. Questions you could ask: what would this patient have presented in an emergency department to clue the triage nurse into this issue of sepsis? If this patient weren’t respond to treatment, what would that look like? How would we respond to that? If their blood pressure started to plummet, what would our first reaction be? When would you start to get concerned with this patient? I know they’re doing okay right now, but what would concern you? A couple more. I know antibiotics are really important in treatment of a septic patient, but how would I know if the ones we’re using aren’t working? Let’s say you have a septic patient and they’re on various antibiotics. Their fever is not going down. Their white count is not going down. Their infection does not seem to be resolving. It puts you in that scenario. What’s the biggest complication we’re facing with this patient? How would I know if that’s beginning to occur?

 

You would think about, “Hey, if I’m taking care of this patient, I put myself in the shoes of the nurse taking care of this patient. Okay, let me think. What would scare the heck out of me? What would I not know what to do about? What’s the biggest complication related to this issue? How would I know it’s occurring or starting to occur?” That’s a big one. No matter what the diagnosis is. If you’re in clinicals, you can sit there and say “hey” to the nurse that you’re following or whatever. Patient is here with a femur fracture. What’s the biggest thing I’m worried about with them? How would I know that that was occurring? Some things are really obvious and some things are not. Those kinds of questions can really help you develop this critical thinking, give you a little bit of a head start, I guess. If you have that mentality that way, when and if those situations present themselves, you’re familiar with, “Okay, how do we critically think and work through this scenario?”

 

That’s critical thinking. Let’s talk care plans. Let me just explain a couple things. A care plan is basically, “Hey, there’s me as a nurse, not as a physician. Me as a nurse notice these few things that are problems. How do I know they’re problems? What are they related to? How do I fix them? How did I do?” Roughly that’s what a care plan is. It is a plan to your care, but there’s some things called NANDA, NIC, NOC. It’s like, “What is all this stuff?” What I want to do is I want to explain those three things and then we’ll get into care plans a little bit more. NANDA, and it’s actually NANDA-I or NANDI. Okay, NANDA. What does that stand for? It used to stand for the North American Diagnosis Association. Used to until 2002. Their organization started expanding quite a bit outside of North America, so they changed their name to NANDA in an International. NANDA-I. That’s what that is. That’s what it stands for.

 

Basically what it is though is they have created this standardized list of nursing diagnoses. It’s this specific list that no matter where you are in the country, all of these diagnoses … The terminology is standardized. This is wonderful because you don’t have a different name for something in New Jersey and another thing in Hawaii. Acute pain is acute pain. Constipation is constipation. Anxiety is this. Some of them are straightforward but some of them … If there wasn’t this standardized list, people could really be creative and use a lot of different terms that weren’t necessarily communicating the same thing. That’s what it is. That’s all it is, is this standardized list. Okay. That’s NANDA.

 

NIC stands for Nursing Intervention Classification. Same concept as NANDA but instead of nursing diagnoses, it’s a standardized list of nursing interventions, things nurses will do in response to an issue. I see this problem. I’m going to intervene with this intervention. I’m going to intervene with this action. All it is is a standardized list. Similar thing with NOC, Nurse Outcome Classification. Standardized list of nursing outcomes. My patient had this diagnosis. I did this intervention. What am I hoping will be the outcome? That is NANDA, NIC and NOC. Really important because it’s important to have research-based and agreed upon terminology, so everyone is talking the same language.

 

I don’t want you to get tripped up on it because all it is is a standardized list. It’s just specific terminology. We’ve got to learn that language. It’s not something that you can read a chapter and just know it. Take some time to really get used to the diagnoses. The familiar ones, the typical ones, the more complex ones, the more confusing ones, the more difficult ones. Take some time to get used to it. You know what? That’s okay. You’re learning. It’s not going to be something you pick up overnight. Okay, so let’s talk about really what a nursing diagnosis is. When we hear that word, diagnosis, we tend to assume what that means. We tend to assume medical diagnosis because really, I don’t know how else we’ve heard that word. Hold on, though. Try to suspend your judgement. Medical diagnoses and nursing diagnoses are two completely different ballgames. Nursing diagnosis is basketball. Medical diagnosis is baseball. They’re still ballgames, but totally different.

 

The medical team makes their medical diagnosis. They write their progress notes. They do whatever. Independently from that, though, the nurse will look at the patient’s clinical picture and develop their nursing diagnosis. These nursing diagnoses will guide the nurses on how to prioritize the care that they’re giving that patient. If you thought that going in to take care of a patient just meant to pass their meds, to clean their bed and to walk them around, it’s not just that. Each patient needs to have specific care tailored to their needs. Patients are dynamic and different. We have to look at each patient and say, “Hey, you have these needs. Because you have these specific needs, I’m going to prioritize my nursing care today based upon those,” if that makes sense.

 

Let me give you the official definition of a nursing diagnosis from that NANDA website. “A nursing diagnosis is a clinical judgement concerning human response to health conditions or life processes or a vulnerability for that response by an individual, family, group or community. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.” Boy, that sounds like a lot of fluff. It’s hard to really figure out what they actually mean. I translated that a little. Here’s my NRSNG translation of that term. “A nursing diagnosis is something that a nurse decides is a priority for their patient after they’ve looked at their entire clinical picture and gathered information from the assessment, report and the chart. These diagnoses will guide the nurse’s care and priorities for that patient.”

 

To come up with this diagnosis, you look at subjective and objective data. That’s confusing to understand the difference between subjective and objective data. I know that is a struggle for a lot of nursing students. We have a wonderful post about that on NRSNG. If you just Google “subjective versus objective data”, it’s one of actually the first things that comes up on Google. It’s a wonderful post. I have a link to it in this actual blog post. That’s a really important aspect but I don’t want to really dive into that. That could be its own podcast. That’s what a general nursing diagnosis is, but there’s actually three kinds of nursing diagnoses. They’re problem-focused, health promotion and risk nursing diagnoses. I want to define each one so you can understand it.

 

Keep in mind all of the information that I’m going over, I wanted to make sure I got from a consistent source. I have cited on our website or on this post that I got a lot of this information from the NANDA website, the official NANDA International website. I have links to the specific pages in here. It’s actually a really great website, a really great resource. If something doesn’t make sense, I encourage you to take a look at that, to see if that might help offer some additional clarity. I had to get a drink. My throat is getting dry here. I’m just talking so much. Sorry, guys. This is a big topic, though.

 

All right. Problem-focused nursing diagnosis. Official definition of that. “A clinical judgement concerning an undesirable human response to health conditions or life processes that exist in individual, family, group or community. In order to make a problem-focused diagnosis, the following must be present: defining characteristics, which include manifestation signs and symptoms, the clustering patterns of related cues or interferences, related factors, etiological factors that are related to or contribute to our [inaudible 00:19:02] to the diagnostic focus are also required.” Here’s my nitty gritty translation. “A nursing diagnosis that is focused on a problem that the nurse identifies after considering the entire clinical picture. You must have defining characteristics and related factors.”

 

Basically I see blank problem and things that are related to this problem are blank. The related to factors. I know this problem exists because I’ve observed or measured blank, the defining characteristics. To give you an example, and this example is on the NANDA International website, anxiety problem related to situational crises and stress – those are the related factors – as evidence by restlessness, insomnia, anguish and anorexia. Defining characteristics. That’s a problem-focused nursing diagnosis. We are focusing on a specific problem. A lot of them are problem diagnoses, to be honest. Next kind is a health promotion diagnosis. It’s exactly what it sounds like. I won’t read verbatim what the website says, but here’s my translation. “This diagnosis focuses on optimizing and promoting the health for that patient. Health promotion. We know this is an appropriate diagnosis because the patient has expressed desire to improve their health. Defining characteristics must be included.”

 

Basically the patient is ready to learn more about blank because they told me they were. The fancy one or the example they give on the website is, “Readiness for enhanced self-care as evidence by desire to enhance self-care.” Pretty straightforward. My last diagnosis is a risk nursing diagnosis. Here’s the official definition of that. “A clinical judgement concerning the vulnerability of an individual, family, group or community for development an undesirable human response to health conditions or life processes. In order to make this a risk diagnosis, the following must be present supported by risk factors that contribute to increased vulnerability.” All right. Ready for my translation? It’s basically a nursing diagnosis that expresses something the patient is at risk for. Naturally risk factors must be included. Here you go. The patient is at risk for blank and I know this because of blank factors. That’s it.

 

Basically the example that they give on the website. “Risk for infection as evidence by inadequate vaccination and immuno-suppression.” Boom, that’s it. Risk factor diagnosis. A couple more terms that are important for you to know. Risk factors. We’ve talked about that. It’s something that would increase the likelihood of something else. Makes sense. We’ve got risk factors but we’ve also got related factors. It’s something that’s related to the diagnosis. You can say associated with, related to, contributing to. They’re focused on the diagnosis. These must be included in focused diagnoses and can be included in health promotion diagnosis but aren’t required. If you have a problem-focused diagnosis, you must have one of these.

 

Defining characteristics. Things that you can witness for yourself or measure for yourself that are related to the diagnosis. You can observe these characteristics with your five senses, but I’m really hoping you’re not using taste. Patient goals is what you want the patient to achieve. Interventions. What you’re going to do to try to get them to those goals and rationales. Let’s use paint as an example. My goal is for the patient to report pain of 4 out of 10 within an hour of giving medication and repositioning. My intervention will be pain medication administration, repositioning, pillow support. Hopefully that’ll decrease their pain level. When I’m writing my care plan, I’m going to use very direct verbage. “I will do blank. The patient will do blank.” I don’t want you to get tripped up on making it sound fancy. Implementation.

 

All that really is is did you do it or not? I know this may seem really odd to include, did you do it or not? Why would I write it if I’m not going to do it? Sometimes, and this happens very frequently in the real world, I have this desire to complete this task but because of whatever happened, I was unable to do so. A very common one is let’s say a patient has a risk for falls. One of the interventions maybe I wanted to do is I wanted to move the patient closer to the nurse’s station. I’m going to put that as my intervention. When it comes time to actually do it, maybe another patient got into that room that’s an even higher fall risk. Getting my patient in there didn’t happen. Something like that.

 

No, I couldn’t do this intervention. Just because you couldn’t do all your interventions does not mean you’re a terrible nurse. This is a plan and some things don’t happen according to the plan. Next thing is the outcomes or the evaluations. What happened, which is the outcome? What did happen? Maybe the patient reported pain on a scale out of 6 out of 10 in 60 minutes instead of the 4 out of 10 that I was really hoping for. Evaluation. Was this an appropriate plan? Maybe I had the goal that they were going to have a lower pain in 60 minutes, but maybe I should have said 90 minutes or maybe I should have repositioned and decreased external stimuli and maybe I should have used a different pain medication and timed it a little differently. Things like that. Those are some important terms that you need to know.

 

I made a couple examples. Actually in this post, I have a link to a really great video that [inaudible 00:25:18]. I thought it was a wonderful YouTube video to really make him come to life and find some value in them, so they’re not just this really dry situation. It seems really straightforward, but why is this so difficult to understand? It’s difficult because you haven’t seen a ton of patients yet and that’s okay. If you’ve never cared for a patient with heart failure before, it’s hard to pick out specific diagnoses that would be appropriate for them and appropriate interventions and realistic goals. It’s going to be a little bit of trial and error. It’s going to be something where you can’t just read a page or a chapter in a book and pass the test with flying colors. It’s something that takes some experience.

 

I do want to give you an example. Let’s put these things together with a patient example. All right. Let’s imagine you’ve got love of your life. I’m going to use a gender neutral name for whomever the love of your life is. Let’s say Alex. Alex is always there for you. You go to bed thinking of Alex and you wake up thinking about Alex. “Oh, Alex. You’re always there. You’re the yin to my yang, the X to my Y, the pan to my gym, the chicken to my waffles.” See what I did there? Let’s imagine that Alex broke their femur in a bicycling accident and was rushed to the emergency department and had urgent surgery. Now they’re recovering from this femur break, this surgery on an orthopedic floor. I know it’s scary or harsh, but bare with me. I want you to understand the importance of this as a nurse.

 

We’ve got nurse A. You’re sitting there right next to Alex. We’re a couple days post-op, still in a lot of pain, still recovering from the situation itself because it’s traumatic. You’re sitting there with Alex. You’ve got nurse A. Nurse A got report. Came in, looked at the chart. They get to work. Passed their meds. Whenever Alex wanted pain meds, nurse A went and got them. They drew the labs and they were ordered. Took Alex to the bathroom when asked. Alex spent about 80 percent of the day in bed. Pain meds made him or her pretty sleepy. While nurse A answered all of the questions that were asked, they didn’t really go the extra mile to explain anything. At the end of the day, they give report and they leave.

 

By the end of the day, you’re sitting there. Keep in mind, you’re sitting there all day. At the end of the day, Alex still needs those pain meds frequently and felt groggy all day. Barely got up and didn’t eat much. Still needs a decent amount of help getting up and sitting down whenever using the restroom and hasn’t really seemed to improve a whole lot. That’s nurse A. Technically nurse A got everything done. Technically everything was completed on time. During the day, Dr. Smith, who was the surgeon that operated on Alex came down and rounded towards the end of the shift while Alex was sleeping. Dr. Smith wrote the following in her progress note, “Transition to oral pain meds, increase ambulation and discharge in the next 72 hours.” That’s nurse A.

 

Let’s talk about nurse B. Nurse B walked in, got report, looked through the chart and got to work. After report, nurse B decided that pain management, promoting mobility, preventing skin breakdown are going to be important to get your BFF home and doing better ASAP. Nurse B looked closely at all of the orders, including the meds and nursing interventions to make sure that nurse B knew how to prioritize care for today. They start out by letting you and Alex know the plan. “Hey, you know what we’re going to do today? We’re going to try to transition from those IV pain meds to oral pain meds for better, longer relief. It’s really important too that you get out of bed as much as possible. I want to get at least 2 walks in but hopefully 3 and I want you out of bed for every single meal. I want you to make sure you’re not sitting on that butt all day because your skin will start to break down. If you decide to sleep, let’s get some pillows and prop you up on your side if that’s comfortable and okay with you.”

 

You and Alex look at each other like, “All right. I know this is going to be a little tough, but hey, if this is what we’ve got to do.” Nurse B gave oral pain meds with the rest of Alex’s meds at the beginning of the shift. Nurse B got Alex up for all three meals and walked with Alex twice. When Alex said he wanted to go take a nap in the afternoon, nurse B came in, got him positioned up on his side and he slept like a rock for an hour and a half. Dr. Smith came by later in the day and rounded while Alex was up in the chair, eating dinner. She wrote in her progress note, “Continue current plan and discharge tomorrow.” At the end of the shift, Alex had not needed another dose of IV pain medication, despite the increased mobility. Alex walked twice, got up to the chair for all the meals and getting up the first few times was pretty tough, but it got easier as the day progressed.

 

By the end of the day, Alex was basically walking himself to the bathroom with just the assistance of a walker and someone nearby just in case. At the end of the day, which nurse had a more successful shift? More importantly, which nurse do you want taking care of your loved one? They both passed all their meds on time, responded to call lights and needs that were verbalized. All went right. Right? Wrong. Nurse A got the tasks done but didn’t have a plan for the shift. Nurse A didn’t have discharge in mind and nurse A just wanted to get to the end of their shift. Nurse A was passive. Nurse B. Nurse B had a plan. Nurse B had a care plan. See what I did there?

 

Nurse B thought about the needs of the patient with a fractured femur and prioritized care for that day. Nurse B communicated. Nurse B made sure their patient progressed towards discharge. We’ve got to add critical thinking back in. We’ve got care plans. Hopefully now you understand the value of the care plan. You add in critical thinking. You have a care plan and it does take critical thinking to come up with the care plan, but as you’re implementing this care plan, you’ve got to fuse critical thinking throughout the day as you implement it. It’s really important that you put these pieces together. You’re creating plans for your patients and you’re implementing them and using critical thinking to create the plan and implement the plan and change things as needed.

 

I promise you guys, this is really, really important stuff. You will use it every single shift and like many nurses today, they’ll joke that care plans don’t matter but they do. They’re using them and they just don’t realize it. They are so important. When you ask, “Will I really need to know this to get through my shifts?” Yes, yes, yes. Absolutely and unequivocally, yes. Pretend I send that in my Professor Slughorn voice in Harry Potter because he’s … I love it when he says, “Absolutely and unequivocally, yes.” I have a couple examples of these care plans using critical thinking in our post and I think they’re really, really helpful. I won’t go through them here because they’re so specific. It’ll make this podcast much, much longer. I really hope that you understand the vital importance of these. I’ve been a nurse 6 years and in school, nursing care plans seems frivolous and stupid and not necessary.

 

I’ve talked to nurses and they’re like, “Oh, we never use those,” but they do. We do. I promise. People just don’t realize that they use them. They use them every single day. It’s really, really important to remember that they are important. Even though they’re difficult and frustrating right now, they probably should be because you just haven’t seen a whole bunch of patients yet. It will get easier. It will become second nature to you. You’ve got to hand in there. Promise they’re important. I promise it will make you a better nurse. Your patients will get better care and better outcomes if you’re using care plans and utilizing critical thinking.

 

All right, guys. Thanks for listening to this episode on critical thinking and nursing care plans. I hope this was helpful for you guys. I hope it’s going to help you piece together how to critically think as a nurse and then what that means and how the nursing care plan is really so vital to everything that we do. I know that we hate them. I know they’re difficult, but it’s really everything that we do is nursing is critical thinking around the care plan of the patient. All right. That’s what we’re doing. We’re providing care for a patient and that’s what this is all about.

 

Head on over to NRSNG.com/criticalthinking to get this massive outlined post with audio, with video, with explanations, with examples and with the free template of nursing care plans. That’s NRSNG.com/criticalthinking. All right, guys. We appreciate everything that you do. We appreciate you being part of this NRSNG family. We are growing. We are reaching nearly every country in the world and you guys are part of that. You guys are everything that we do at NRSNG. I want you guys to know that. This isn’t about us. This is about you guys and you’re the heart of soul of everything we do. With that said, you guys know what time it is now. It’s time to go out and be your best self today. Happy nursing.

 

Date Published - Oct 3, 2016
Date Modified - Jun 25, 2018

Jon Haws RN

Written by Jon Haws RN

Jon Haws RN began his nursing career at a Level I Trauma ICU in DFW working as a code team nurse, charge nurse, and preceptor. Frustrated with the nursing education process, Jon started NRSNG in 2014 with a desire to provide tools and confidence to nursing students around the globe. When he's not busting out content for NRSNG, Jon enjoys spending time with his two kids and wife.