SCCMPod-556: Building Lifelong Learning Habits for Nurses and APPs

Dr. Gambles Farr: Hello and welcome to the Society of Critical Care Medicine podcast. I'm your host, Samantha Gambles-Farr. Today, I'm joined by Brian Boling, acute care nurse practitioner, to continue our series focused on addressing the unique professional developmental concerns of healthcare workers at the beginning of their career.

Dr. Brian Boling is an advanced practice provider in the Department of Anesthesiology, Division of Critical Care Medicine at the University of Kentucky and an associate professor in the School of Nursing at Georgetown University in Washington, DC. Currently, he splits his clinical time between the neurocritical care and surgical critical care services. In addition to his clinical duties, Brian works in the UK's APP Critical Care Fellowship Program, coordinating simulations labs in the point of care ultrasound or POCUS teaching.

In his academic role, he teaches in the adult gerontology acute care nurse practitioner program, where he also serves as the coordinator of POCUS education. Dr. Boling is a nationally known speaker, author, and co-host of the popular medical education podcast, Critical Care Scenarios. He is active in several professional organizations, including Society of Critical Care Medicine, the Neurocritical Care Society, and the American Association of Critical Care Nurses, and is the current president of the Association of Postgraduate APRN Programs.

Brian lives in Lexington, Kentucky with his wife, Sarah, children, Caleb and Molly Kate, a dog, Maisie, and two cats, Oreo and Tigger. Dr. Boling, thank you so much for being here on our podcast today. What an amazing description of all your work.

I think before we get started, I would like to give you an opportunity to share any disclosures if you have any to report.

Dr. Boling: Sure. Thanks so much for having me. The only disclosure I think I would report is, so in addition to being a formal educator, professor and teaching in the fellowship program, I consider myself an informal educator as well.

I have the podcast that you mentioned, Critical Care Scenarios, as well as a website that I started a couple of years ago called criticalcarenotes.com. That's just a place where I share mostly the resources, the kind of resources that we're going to talk about here later on in the podcast, I'm sure, for my students and stuff, and it's publicly available. So if anybody wants to check that out, they can see some of the stuff I'm talking about.

I'm sure that'll come up.

Dr. Gambles Farr: Okay, perfect. And so in us developing these series, we're trying to come up with subject matter that is specific for healthcare workers, specifically nurses or APRNs who are at the beginning of their career. Because as you know, you start your nursing career and you're a novice.

And then if you become an APRN or an APP, you have another opportunity to be a novice once again. And so in developing this series, we thought it was important to really focus on that. And so I guess I would start off by asking you the question of what made this subject matter particularly important to you?

Dr. Boling: So I think for me, it started off when I was a student myself. So I was sort of a non-traditional student. I went to nursing school later in life in my thirties, and I was just sort of looking for ways to sort of enhance my learning beyond what I was getting in school.

And I discovered podcasts at the time and started listening to podcasts. I listened to particularly Jeff Guy's trauma ICU podcast, if anybody's old enough to remember that. And that really helped me learn.

And I found podcasts that I listened to that helped me study for the CCRN and really just sort of develop as a nurse. And when I went into MP school, the same thing, right? I started with podcasts and blogs.

I'm old enough to remember blogs. Some of you probably don't know what I'm talking about. And that's what kind of got me through grad school too, right?

It was supplementing my own learning and even as a new provider. And so as I kind of became more comfortable and got into this sort of mid, I like to think of myself as mid-career, or maybe I'm late career at this point, I don't know. And especially when I got into formal education, sort of saying, these were tools that helped me along the way.

And now I kind of want to turn around and share those with other people who might be in the same boat.

Dr. Gambles Farr: Right. Growing the nursing profession and growing people who are coming behind you is something definitely I feel like people who are leaders within nursing themselves are always focused on. And so as a healthcare leader, once you reach a certain part in your career, you're always looking for opportunities to reach back into novice nursing or people who are novice nurse practitioners and helping to find ways for them to improve their development in their career.

Can you discuss that a little bit in kind of how you feel we as healthcare providers can help those people who are just starting out in their career to help themselves have opportunities for advanced learning?

Dr. Boling: Yeah, absolutely. So I think you're right. I think you get to a point where, you know, I like to think of myself as a lifelong learner and there's always more things I can learn.

There's always more stuff I can know. But at some point you do get to this point where you feel like, you know, not that I know everything, but I have a good handle on things. And learning for the sake of learning is not as exciting anymore.

And that's when I think that people at this stage of your career can really turn around and be the leaders. And I think about when I was a nurse, I started off in a cardiac ICU and I worked with a handful of nurses who had been doing this for 20, 25 years. And that's pretty rare these days, but back then it was not.

And every night I worked a shift with them. I was just like soaking it up, right. Teach me stuff.

I want to learn from them. And I don't think any of them would have ever thought of themselves as an educator, but they certainly were. And I think now we're in a world where that happens less and less at the bedside, less and less in a kind of informal work scenario.

But we have the opportunity to do it through tools like social media, through tools like podcasting, et cetera. And I think that's a real opportunity for folks who are a little more advanced in their careers. They understand all the basics.

Maybe I'm learning the newest and greatest developments, but the kind of fundamentals I've got down cold. And that's a chance that they can take to sort of build up the people that are coming behind them.

Dr. Gambles Farr: Right. Because even from a standpoint, I know you work in the surgical ICU and you also work in neurocritical care. There's a lot of opportunities, even as an advanced practice nurse for you then to translate and give education to bedside RNs that are working with you.

And I think that it also helps promote some professionalism within nursing as well, because then they understand exactly what the APRN does and the knowledge base of what it takes to be an APRN, right?

Dr. Boling: Absolutely. And you know, one thing I said when I was in NP school was I felt like I learned stuff that I already knew, stuff I learned in nursing school and stuff that I did every day as a nurse, but I learned it to a much deeper level. And I remember at one point thinking, aha, that's why we do that, right?

And I had always sort of just figured that we did this because X, Y, and Z, but I was wrong. And there was really a deeper meaning to it. And I remember thinking like, gosh, I wish that I could have this sort of education, even if I wasn't going to become an NP, right?

And not every nurse is going to go and get a master's degree to continue to be a bedside nurse. But those of us who do have a master's or a doctorate can then sort of, like you said, pass along that information to sort of help them understand better, you know, some of the stuff that maybe gets short shrift in nursing school or things that we do and we don't really understand why. If you do understand why, and you don't have to be an NP to do this, right?

You can just be, like I said, a nurse who's got lots of experience, who understands, you know, why we do such and such to sort of explain it to the bedside nurses or your newer bedside nurse colleagues so that they have a better understanding instead of just carrying out a task for the sake of carrying out a task.

Dr. Gambles Farr: Yes, because I think that that's honestly what transitions someone's ability in their care and their thought process is not to just be doing the task, but to really have a great understanding as to the medical management and the why's behind things that we do. And so I know whether you are a seasoned nurse or an APRN, just having those opportunities to share that information with someone, you really underestimate the value that that can have for that person who is a new grad or is a new nurse practitioner, or maybe they're within their first year. You know, we always think of novice as someone who just graduated, but there's novelty and novice description, even for people who may be a year, two years out, right?

Oh, absolutely.

Dr. Boling: Listen, I've been an acute care nurse practitioner for close to a decade now. And if you took me out of the ICU and put me in a cardiology clinic, I would be a novice. I mean, I do a lot of that stuff day to day, but in this setting of the ICU, and it's different.

So I think there's always opportunities that we're all novices and we're all experts. But I do think it's hard to remember back when you weren't an expert, you know, it's hard to remember, like, do you remember what it was like when you didn't know and such and such. And it's really hard if you've been doing this for a while to do that, to put yourself in the shoes of a new person.

Dr. Gambles Farr: I think that's one of the reasons why I keep students with me, you know, really understanding what the role of the student or the new person who's going through the process that also helps as well.

Dr. Boling: Absolutely. I think that's one of the reasons I really enjoy teaching in general is like you said, because it helps me to understand material better. It helps me to understand what people are going through, right?

But looking back and going, oh, I get what it's like to be a student.

Dr. Gambles Farr: Right. And kind of piggybacking on that, you know, we've talked about a couple of ways that we can stay up to date just amongst ourselves sharing information, but do you have ways that you promote with your students besides gathering information, kind of keeping it all in one spot? Do you have best practices that you kind of share with your students as far as what they can do and what information is good, what information is not good, where to find great information?

Do you have best practices as far as what you share with anyone you come in contact, honestly?

Dr. Boling: Yeah. And I find more and more that students are already doing these things. When I was a student and I was listening to podcasts all the time on social media, I feel like I was a little bit of an outlier, but more and more of my students, I'll say, you know, I recommend such and such a podcast and half of them will say, oh, all right.

I love that podcast. You know, I already listened to that or I've already following that person or whatever. You know, I think the resources that I typically recommend to students are podcasts tend to be very popular.

Social media used to be Twitter, which is now X was the big thing. I think from a medical standpoint, that's sort of died. I'm not on it very often anymore.

And when I am, it feels like there's not nearly as much going on as there used to be, but blue sky has sort of taken its place to certain degrees. Like I said, I still like blogs. A lot of younger colleagues now are like, I can't hang with you with blogs, but I still like a good blog, but really whatever you're picking, right.

And to a large degree, the media is up to you, right? It's your preference. Do you prefer to read?

Do you prefer getting things in small bites? Do you like video? Do you like audio?

But whatever you do, I think it's important to just pick good and be able to filter signal from noise, right? So I would sort of recommend when you're looking at a podcast, when you're looking at somebody to follow on social media, look at a couple of things. One good indicator is, you know, what kind of following do they have?

If you've got somebody on social media who has thousands and thousands of followers, if you've got a podcast that has lots and lots of subscribers, it's probably good content, right? Now there's a little bit of a double-edged sword there because we all know that there's a lot of people who get lots of follows, lots of likes on social media who are snake oil, Charleston people who don't know anything about healthcare. But if you're looking at somebody who is a nurse practitioner, if they're a nurse, if they're a physician, the reason they have a big following is they're probably pretty decent, but you know, you need to check for yourself.

So what I always say is find something that they've done that you sort of know a little bit about and take a listen, right? So if they have a podcast, scroll through and see if there's a podcast episode, that's something that's sort of your area. And you'll kind of know if they make sense or not, and listen to it, spot check their social media posts and things like that, and check it against what you know to be true.

And then once you've sort of established that, okay, I've been listening to this guy for 10 episodes and fact-checking him, and he's always spot on, then you can sort of back off a little bit because it does get tiresome to have to Google everything all the time to see, well, what does this evidence actually say? Some people will cite studies or evidence in some places, and some people don't. And I don't think there's anything wrong with people who don't cite them, for example, as long as what they're saying is legit.

And so you do have to sort of spot check these things. But like I said, once you sort of establish that they know what they're talking about, they're not selling you some voodoo, it's probably okay to kind of back off and just enjoy it.

Dr. Gambles Farr: Yeah, that goes back to the whole trust, but verify thought process behind most of the things we do in nursing and in medicine. You always listen with a trusting heart, but you verify the information that you're being provided with. And so I think that that's an important aspect, because there are some people who have medical content, but I think you also have to decipher between those who are providing educational versus entertainment or anecdotal information.

And so I think that those are additional caveats that we have to think about when we're looking to increase our knowledge base and our professional development as well. Because while others are nice, they may not lend to professional development in the way that you may be looking for.

Dr. Boling: Absolutely. And I always say that you should not be practicing nursing, medicine, whatever, pharmacy, based solely on the recommendations of somebody with a podcast, right? It's very easy to set up a podcast now, anybody can do it, but you can use that as a tool, right?

And so we always say when we close our podcast episodes, that a lot of what we're saying is just our personal opinion and doesn't represent any organization we're affiliated with or et cetera. But we also say that you shouldn't be basing your entire practice on what we're saying, right? So take what we say, and if it's helpful, it's helpful.

But like you said, trust but verify. And I hope that nobody out there would base their entire professional practice on a YouTube channel. But certainly you want to sort of verify a little bit, does this make sense to what this person's saying?

Dr. Gambles Farr: Right, right. And discussing how that translates into practice every day for those who are novice, but then also just like we were talking about a few minutes ago, how if you're in the middle of your career or whether you're at the end of your career, if you're not a lifelong learner as a person who's in healthcare, no matter where you are in continuum of healthcare, then that's kind of problematic within itself.

But how does this kind of translate for someone who is in those caveats where they're like middle of the career, they're into the career and kind of what they can do as well. Because I think just like we were talking about, there's opportunity when you switch from one role or you go to another hat, and you may be an expert in one field, but then you turn around and you're doing something brand new. And now you're a novice all over again.

And how does that kind of correlate?

Dr. Boling: Yeah. So I think if you're in a position where you're changing fields or changing roles, and you are a novice again, and so a lot of the novice rules apply, and it's sometimes hard and very humbling to be an expert for a long time, and then to do something new. I'll give you an example.

When I was a CTICU nurse, I had a new nurse new to our unit who had been asked to And this nurse, she actually had been a nurse longer than me. She'd been a CCRN longer than me. She had much more experience than me, but she had never done anything with cardiac surgery.

And I asked her kind of, well, why did you want to do this? And she said, I wanted to be challenged. And she struggled a little bit.

We would meet after the shift and kind of talk about how things were going. And one night she said, I just miss being good at my job. I miss feeling like I know everything.

And I said, well, you said to me that first night you wanted to be challenged, and this is what it feels like to be challenged. And that is humbling. And you have to sort of make a decision.

Do you want to do that, or do you want to go back and do what you're good at? And there's no shame in that. I told her, right?

There's nothing wrong with saying, I want to go back and do what I've always been good at. The world needs people who are good at their jobs. But if you want to strike out and learn something new, there is going to be a little bit of humbling to it.

Dr. Gambles Farr: Yeah. There's a vulnerability that comes with that. In that vulnerability, you have to be an active and willing learner again.

Earlier you had kind of said something about really getting down to the nuts and bolts of what's important as far as who you're taking care of and why you're taking care of them, right? And so can you speak to that a little bit more? Because I found that when you're doing things that seem very exciting, there's always, I'd like to call them, for lack of a better phrase, the sexy things everybody wants to do.

And, oh, I know how to do this. Knowing that information is good, but then how does that apply when you are a novice and how you can relate that back to nuts and bolts thought process of learning?

Dr. Boling: Yeah. So I think what you hit upon there is one of the really critical things about self-directed learning, right? And I'm a big proponent of self-directed learning.

Like you said, being a lifelong learner, you have two options. You can pay other people to teach you, or you can be a self-directed learner. And most of us don't have the option just to continue to get degree after degree.

But I think one of the biggest challenges to being a self-directed learner is the lack of curriculum. And I'm going to get a little bit nerdy with academic stuff here, but as a professor, when I sit down to lay out a course, I look at what is important for the students to learn. What are the learning objectives that I want them to meet?

What are the goals of this course? And not only that, but how does this course fit in with the overall plan of study, right? With their entire degree.

When you take a course offered by a university, or even if you do one of these like Coursera courses or whatever, they do the same thing, right? Somebody has laid out like, these are the things that you need to know. These are the objectives that you need to meet.

When you're doing self-directed learning, you don't have that. And the biggest pitfall that you can fall into is focusing on the wrong things, right? And you mentioned, I think the two biggest pitfalls, the one you mentioned, right, is looking at what's hot, what's sexy, what's cool, right?

If you look on social media, you're going to find a lot of stuff about ECMO. You're going to find a lot of stuff about Roboa and about video laryngoscopy and the newest, coolest trends in organ transplantation and stuff like that. But for 20 years in critical care nursing, I'll tell you what makes the difference in 90% of the patients that walk out of the ICU is not those things.

It's the little things that we do every day, the stuff that's not cool, the stuff that's not hot, that nobody wants to post about on social media, but that's the important stuff. And so if you don't have some sort of curriculum laid out, the temptation is to just study the stuff that's cool, the stuff that's interesting. And that's fine.

If you get to a point in your career where you're like, I've got all the basics down. Now I want to learn the flashy stuff. But if you're a novice starting out and you're just focusing all your efforts on POCUS, I love POCUS, you mentioned I teach POCUS all over the place.

You're studying all about POCUS and all about ECMO and you're missing out on some of the basics, then you don't have a very good foundation. The other problem is we tend as human beings to focus on the things that we like. And a lot of times we focus on the things that we're already good at.

And I'll give you an example. When I was studying for my nurse practitioner boards, I would make these flashcards. Kids, if you're listening, flashcards used to be these things that people used to study with, but I would make these flashcards and study aids.

Dr. Gambles Farr: I think people still use flashcards. It's so funny you mentioned that. That's so funny.

Dr. Boling: I feel like the older I get, the more my kids and the more the students and residents that I work with are more similar to my high school and middle school kids in that they don't understand some of the old school things I talk about. But I would make these study notes or flashcards and stuff. And I would spend a lot of time focused on things like cardiac surgery and cardiac physiology, which to be fair is a big important part of the boards.

But I was a cardiac ICU nurse. I didn't really need to study that stuff. I had that stuff down pretty much.

ID was the thing that I was really weak at and really struggled with choosing antibiotics, for example. And I chose to not focus on a lot of those things. And the reason I did was because I could sit down and go do these cardiac flashcards and I'd get every one right and feel really good about myself.

They're like, you're so smart. You're so ready for this test. But then when I get those ID questions, I would go, oh, I feel like I know this.

And I'd guess and then flip over and now I'm wrong. And so I don't feel good about myself. Nobody wants to feel bad about themselves.

So we focus on the things that we're good at. But the problem is I don't grow if I focus on the things I'm good at. I grow when I focus on the things that are painful, the things that are hard.

And so I think if you have a curriculum that forces you to focus on the things that are both not cool and hot and things that are things that I'm weak at, you're going to grow more. So I always tell students, when you're sitting down to sort of design this self-directed learning, map out a curriculum, sit down and be honest and say, what do I need to know and make sure that I'm hitting those things, even if it's something that I'm not interested in. But if I'm honest with myself, I need to know it or something that I wish I knew better, but I just don't.

And I'm going to feel real bad about myself because I'm going to get a lot of those questions wrong. Yeah, that's what you need to study.

Dr. Gambles Farr: Yeah, I think that everything that you said, just for the record, before I start that thought process, I was the queen of note cards in school, the absolute queen. So yeah, I remember note cards and you're right. A lot of people do not use that methodology of learning, but it works.

It worked great for me. But I think that the things that you said were very poignant in the fact that even when we're in school, whether in whatever type of school that you're in, if you have some type of certification that you have to go through, because we all do at the end, right? So in teaching the students, you take that pre-test and it shows you where your weaknesses are, right?

Or where you need to study a little bit more. I think that like you were saying, you can still take that information and apply it after you become a provider or a RN, an APRN, a PA. You can take that information and then continue to still expound on it so that you become stronger in that subject matter.

I always tell my students, I always say, we want to make sure that you're a safe provider and there's things that are just common in this world and you need to know those things to the T. Those are the things that you really have to focus on and get those things down. So ID was also one of my things.

I think that a lot of people struggle with that. So thank you for sharing that part of your journey. One of the last questions I wanted to ask you is there are so many things in this world and there's so many options as far as learning.

People have families, they have pets. I mean, just reading your description of what you do and how engaged you are in nursing and in the medicine field, how can you mitigate time and make sure that your time is as consolidated for this as possible, knowing that you have so many options, but everybody's so busy in their lives. How can you really hone in on that?

I know you gave a lot of options today, but if you had to give a couple of things to kind of help people hone in on timing, what would those things be?

Dr. Boling: Yeah, that's a great point, right? So we're all very busy and I try to balance my work and my life as well. And so I used to spend all my free time, you know, I would listen to podcasts in the car, I would listen to podcasts at the gym, I would listen to podcasts when I'm out of the yard.

And I don't always do that anymore because I do like to have a little bit of work-life balance. And now I might listen to a non-medical podcast, you know, or listen to music or whatever. But I do think that, especially when you're new and you're looking to try to maximize your time, is to just find those opportunities, right?

Most of us, all of us, right, have a commute of some sort. There's time where it's you on the way to the hospital to do your job and on the way home. So devote some of that time to that.

You know, one way to do it with balance is to say, on my way to work, I'm going to listen to a medical podcast. On my way home, I'm going to listen to something fun, you know, and that does sort of help a transition to like, I'm leaving home, I'm going to work. So I'm getting on the way there, I'm already getting in work mode.

And on the way home, I'm getting out of work mode, right? I'm going to listen to music, I'm going to listen to a book, I'm going to listen to a podcast about conspiracy theories or whatever, and sort of transition away from work. And I think that helps you maximize your time while also maximizing that balance.

But one of the nice things about this sort of self-directed learning, particularly with the kind of free or low cost, open access stuff on the web, is that you can just sort of do it for short chunks of time. Like I said, I read blogs still. I have a blog reader on my phone, and I will devote a few minutes in the morning while I'm drinking coffee, just scanning through those blogs, just to see if there's anything of interest.

And sometimes there's not. Sometimes I go through and go, yeah, fine, whatever. I'm not really, nothing does it for me.

But sometimes I will find something and go, hey, look, I don't have time to read this now because I want to devote time to it, but I'll bookmark it for later. So maybe tonight before I go to bed, I'll take a few minutes and read this, or later if I get some time, you know, but I kind of block off a little chunk of time just sort of to skim. And same thing with social media.

I'll take a few minutes and just sort of scroll through Blue Sky, scroll through Instagram, and just see if there's anything interesting. And if there is, I'll bookmark it and say, okay, I'm going to come back to this later when I can devote some time to it.

Dr. Gambles Farr: Yes. Thank you so much for those. I think that having work-life balance and just overall, we really have to focus on our mental health and making sure that we take time and opportunity to tend to ourselves and to our families and to those that are important to us.

And I think that in our field, we are in this field because we care about people and we dedicate a lot of time to making sure that we are providing the best care for our patients in our community. But we need to also realize that we are also part of that community and we need to take care of ourselves as well. And so with that, is there any last parting words that you have as it relates to the self-directed learning, the novice provider, the novice RN, any parting words you'd like to provide?

Dr. Boling: Yeah. I think the biggest thing is to just be honest with yourself about what you know and what you don't know. Be honest with yourself about what matters too, right?

You don't have to know everything. I think that was something else that I struggled with when I was new was feeling like I had to know everything. And in reality, my job focuses on a certain subset of people, right?

I mentioned earlier, if you took me out of the ICU and put me in a clinic, I'd be a novice. I don't have to know the clinic stuff. So why would I kill myself to try and learn those things?

So be honest with yourself about what you need to know, about what you want to know, and then sort of just put something together and take it easy. It'll come. You don't have to know it all today either.

Dr. Gambles Farr: Great. And with that, this concludes another episode of the Society of Critical Care Medicine podcast. And don't forget, if you're listening on your favorite podcast app and you like what you heard today, consider giving us a rating and leaving a review.

For the Society of Critical Care Medicine podcast, I'm Samantha Gambles-Phar signing off. Until next time, take care.

Announcer: Samantha Gambles-Farr, MSN, NPC, CCRN, RNFA, is a nurse practitioner intensivist at University of California, San Diego Health in the Department of Trauma, Surgical Critical Care, Burns and Acute Care Surgery. She also serves as adjunct faculty at University of San Diego Hahn School of Nursing and Health Science in its Nurse Practitioner Program. Join or renew your membership with SCCM, the only multiprofessional society dedicated exclusively to the advancement of critical care.

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