Clinical Forethought
Clinical Forethought: its that thing nurses do that make them look psychic. I remember being in awe as a young student and thinking, “How the heck did that nurse know that??!” Luckily for us, it’s a real thing… no, not the part about being psychic. I am talking about the awesome ability to see things coming from 1,000 miles away.
Here you will learn:
Here you will learn:
- What clinical forethought is
- What goes into this skill
- Ways to develop it
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What is it?
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Pre-Reqs
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3 Tips
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Pro-Tips
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Still Unsure?
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It is the habit of thought that helps clinicians anticipate possible clinical paths and outcomes.
How this ability grows is by having background knowledge (textbook smarts) and experience (Street smarts).
Knowledge + experience = Clinical Forethought
How this ability grows is by having background knowledge (textbook smarts) and experience (Street smarts).
Knowledge + experience = Clinical Forethought
Besides time and experience, there are 5 main things that go into clinical forethought. Let’s start with the most important:
#1) Clinical Grasp
You can’t very well see what’s coming if you don’t see what is already there.
Think of it this way: Clinical Grasp is you knowing what street you are standing on, and clinical forethought is the GPS on your phone when you’re trying to get somewhere. Have you ever tried to get directions on google maps without it finding your current location? It just doesn’t work.
#2) Knowledge background
You will need to have a good textbook/science background of what you are dealing with. If you don’t know something, it is ok (we can’t know everything) but you will have to crack open a book or do some self-teaching.
#3) Potentiality-Think
The habit of thinking, “What if..?” and then DOING SOMETHING to be ahead of the situation. This is a crucial first step to preparing yourself and the environment to be able to act quickly if/when the time comes.
#4) Anticipation
Of future demands, resources, constraints, and tasks. Don’t wait for the situation to make you it’s b*tch (excuse the french). Anticipating gets you ahead of the game.
#5) An open-mind
Again, having an open mind is key here. You can’t very well foresee what is coming if your mind is set on one particular thing. Being closed minded is equivalent to being blind because instead of looking at what actually is, you start to try to fit what you see into a pre-existing mold in your mind and that will handicap you.
The summary of all these moving parts mean that as you gain more experience, you will start to have an understanding of what to expect. And when you know what to expect, you’ll start to see what’s likely to happen.
#1) Clinical Grasp
You can’t very well see what’s coming if you don’t see what is already there.
Think of it this way: Clinical Grasp is you knowing what street you are standing on, and clinical forethought is the GPS on your phone when you’re trying to get somewhere. Have you ever tried to get directions on google maps without it finding your current location? It just doesn’t work.
#2) Knowledge background
You will need to have a good textbook/science background of what you are dealing with. If you don’t know something, it is ok (we can’t know everything) but you will have to crack open a book or do some self-teaching.
#3) Potentiality-Think
The habit of thinking, “What if..?” and then DOING SOMETHING to be ahead of the situation. This is a crucial first step to preparing yourself and the environment to be able to act quickly if/when the time comes.
#4) Anticipation
Of future demands, resources, constraints, and tasks. Don’t wait for the situation to make you it’s b*tch (excuse the french). Anticipating gets you ahead of the game.
#5) An open-mind
Again, having an open mind is key here. You can’t very well foresee what is coming if your mind is set on one particular thing. Being closed minded is equivalent to being blind because instead of looking at what actually is, you start to try to fit what you see into a pre-existing mold in your mind and that will handicap you.
The summary of all these moving parts mean that as you gain more experience, you will start to have an understanding of what to expect. And when you know what to expect, you’ll start to see what’s likely to happen.
Practice the following tips in this order:
#1) Start thinking ahead, AKA: Potentiality-Think
In any given scenario, there are unlimited potentials… or so it seems. At first, without much experience, it will be hard to narrow down what is likely to occur. But by applying yourself (tip #3) and growing your experience, over time you will get a grasp on trends, patterns and likely trajectories. You’ll start to do things like predicting what you need to be prepared for, or catching a problem before it becomes a problem or accurately predicting things that occur, etc.
ACTION: Start anticipating what your future needs will be.
-What supplies/technology/staff/access/medication will I need for the likely scenarios I anticipate?
-Do I have everything I need to give care to this patient? To take action quickly if the worst happens?
-What tasks do I have ahead (lab draws, drip rate changes, glucose checks, etc)?
#2) Verbalize your hypothesis
Whether out loud or in your mind or on you brain sheet, this is an important step because it will shape the way you start prioritizing. For example, if you anticipate your patient is going into (or is at risk for) sepsis, your priorities will shift to stay ahead of it, and you will go about your tasks differently than say, if you DIDN’T suspect sepsis or even if you anticipate a different trajectory altogether.
Its important to say that having a hypothesis goes hand in hand with thinking ahead. As your skill gets stronger, tip #1 and #2 often happen simultaneously.
Start by stepping back and thinking of at least 3 possible clinical trajectories at the start of your day or when a situation evolves. What 3 things could likely occur for your patient as the day/situation progresses? Form a hypothesis and reflect at the end which one was the correct hypothesis. Then, you’ll be able to mull over why that ended up being the case. This leads into our next tip:
#3) Apply Yourself- Heighten Your Attentiveness
Train yourself to be attentive to as much as possible and to learn from every clinical scenario you are immersed in and every patient you work with. Some details don’t make sense until after the fact, so gather as much of them in your mind as possible. After your shift, don’t just go home and never think about your day ever again:
Start to reflect on your experience that day, reflections such as:
-What did I learn that surprised me today?
-What actions/interventions did I do and what outcome did they have?
- Could I have done them differently or better? If so, how will that change the way I do things in the future? (Time management, etc)
- Which of my hypothesis were correct (or wrong) and why?
As time goes on, you will find that you will take care of similar patients and can apply what you have learned in the past to your present situation. Learn, and tweak. Learn and Tweak. Rinse and repeat the cycle until you master it. This is the Art of Intentional Practice.
#1) Start thinking ahead, AKA: Potentiality-Think
In any given scenario, there are unlimited potentials… or so it seems. At first, without much experience, it will be hard to narrow down what is likely to occur. But by applying yourself (tip #3) and growing your experience, over time you will get a grasp on trends, patterns and likely trajectories. You’ll start to do things like predicting what you need to be prepared for, or catching a problem before it becomes a problem or accurately predicting things that occur, etc.
ACTION: Start anticipating what your future needs will be.
-What supplies/technology/staff/access/medication will I need for the likely scenarios I anticipate?
-Do I have everything I need to give care to this patient? To take action quickly if the worst happens?
-What tasks do I have ahead (lab draws, drip rate changes, glucose checks, etc)?
#2) Verbalize your hypothesis
Whether out loud or in your mind or on you brain sheet, this is an important step because it will shape the way you start prioritizing. For example, if you anticipate your patient is going into (or is at risk for) sepsis, your priorities will shift to stay ahead of it, and you will go about your tasks differently than say, if you DIDN’T suspect sepsis or even if you anticipate a different trajectory altogether.
Its important to say that having a hypothesis goes hand in hand with thinking ahead. As your skill gets stronger, tip #1 and #2 often happen simultaneously.
Start by stepping back and thinking of at least 3 possible clinical trajectories at the start of your day or when a situation evolves. What 3 things could likely occur for your patient as the day/situation progresses? Form a hypothesis and reflect at the end which one was the correct hypothesis. Then, you’ll be able to mull over why that ended up being the case. This leads into our next tip:
#3) Apply Yourself- Heighten Your Attentiveness
Train yourself to be attentive to as much as possible and to learn from every clinical scenario you are immersed in and every patient you work with. Some details don’t make sense until after the fact, so gather as much of them in your mind as possible. After your shift, don’t just go home and never think about your day ever again:
Start to reflect on your experience that day, reflections such as:
-What did I learn that surprised me today?
-What actions/interventions did I do and what outcome did they have?
- Could I have done them differently or better? If so, how will that change the way I do things in the future? (Time management, etc)
- Which of my hypothesis were correct (or wrong) and why?
As time goes on, you will find that you will take care of similar patients and can apply what you have learned in the past to your present situation. Learn, and tweak. Learn and Tweak. Rinse and repeat the cycle until you master it. This is the Art of Intentional Practice.
Pro-Tip #1
See your practice as a RESPONSE-BASED PRACTICE
We often hear “Evidence-Based practice” and that’s all fine and great. But this really applies more to the science behind protocols and procedures and all that fancy stuff. We’ve all heard the saying “Patients did not read the textbook”, and to know what works for THIS particular patient, there is only one way to find out; and that is by developing a response-based practice. What is this? It is the practice of doing, and then observing in the here-and-now.
For every intervention that you do, notice what happens after you do it and why. Don’t just do 5 different interventions and wonder why suddenly your clinical grasp is out the door. This is particularly true for titrating drips. If your patient is on 4 different vasoactive drips and you are tinkering with them. Try (if possible) to tinker with just one at a time, then notice what happens, so that you can get a feel for what drug is doing what to the patient. But if you just messed with all 4 of them simultaneously, and now your BP is down the toilet, you wont know why and what you can do about it. Alternatively, if you know which drug is doing which affect, not only will you know how to best support the patient with the least amount of intervention, it’ll give you clues into what is happening with the patient physiologically because each drug has its own mechanism of action.
Pro-Tip #2
Notice The Unexpected.
Nurses get used to certain recovery trajectories and responses to therapies over time. But when these expectations are not met, the expert nurse starts to pay more attention to the responses the patient is having to current interventions and they start to think about WHY. By noticing what response is absent/present, you will go on a search for answers, and that will lead you to notice the unexpected. You can’t always predict EVERYTHING. But you CAN train yourself to see what you didn’t expect before it is too late.
You can do this by having engagement with the patient and openness to the situation. If you are seeing something you didn’t expect, let go of your old hypothesis and become a detective to regain your sense of clinical grasp.
See your practice as a RESPONSE-BASED PRACTICE
We often hear “Evidence-Based practice” and that’s all fine and great. But this really applies more to the science behind protocols and procedures and all that fancy stuff. We’ve all heard the saying “Patients did not read the textbook”, and to know what works for THIS particular patient, there is only one way to find out; and that is by developing a response-based practice. What is this? It is the practice of doing, and then observing in the here-and-now.
For every intervention that you do, notice what happens after you do it and why. Don’t just do 5 different interventions and wonder why suddenly your clinical grasp is out the door. This is particularly true for titrating drips. If your patient is on 4 different vasoactive drips and you are tinkering with them. Try (if possible) to tinker with just one at a time, then notice what happens, so that you can get a feel for what drug is doing what to the patient. But if you just messed with all 4 of them simultaneously, and now your BP is down the toilet, you wont know why and what you can do about it. Alternatively, if you know which drug is doing which affect, not only will you know how to best support the patient with the least amount of intervention, it’ll give you clues into what is happening with the patient physiologically because each drug has its own mechanism of action.
Pro-Tip #2
Notice The Unexpected.
Nurses get used to certain recovery trajectories and responses to therapies over time. But when these expectations are not met, the expert nurse starts to pay more attention to the responses the patient is having to current interventions and they start to think about WHY. By noticing what response is absent/present, you will go on a search for answers, and that will lead you to notice the unexpected. You can’t always predict EVERYTHING. But you CAN train yourself to see what you didn’t expect before it is too late.
You can do this by having engagement with the patient and openness to the situation. If you are seeing something you didn’t expect, let go of your old hypothesis and become a detective to regain your sense of clinical grasp.
The good news for us all is that clinical forethought does not have to be precise in order to be correct. It only needs to be in the right direction. For example, you don’t need to foresee that your patient might develop pulmonary edema. You just have to have a suspicion that something might be happening with the respiratory status/lungs. This vague suspicion will make you hyperaware and ready to notice and respond.
While you gain confidence in this skill, use the expertise of those around you. Touch base with your preceptor or doctor. Ask them, “What do you expect from this patient at this time?” or “What trajectory do you see happening here?” and use their answers to help you see the situation as they do.
While you gain confidence in this skill, use the expertise of those around you. Touch base with your preceptor or doctor. Ask them, “What do you expect from this patient at this time?” or “What trajectory do you see happening here?” and use their answers to help you see the situation as they do.
30-Second Summary
- Clinical Forethought: the skill that makes us look psychic.
- It is built on clinical grasp. You also need knowledge background, potentiality-think, anticipation and an open mind
3 Ways to build this skill:
- Start thinking ahead; AKA Potentiality-Think
- Have a hypothesis and verbalize it
- Apply yourself and heighten your attentiveness