The ICU Role That Teaches Nurses to Think Like Providers

Many nurses aspire to become CRNAs, but long before you ever administer an anesthetic, long before you step inside the operating room as a nurse anesthesia resident, something else has to happen first. You have to begin to think differently. You have to start seeing the bigger picture. You have to move beyond simply recognizing that something is wrong and begin asking why it's happening, what comes next, and how the situation is likely to unfold. And in many ways, that's the beginning of the transition from nurse to provider. Today's episode explores a nursing role that creates opportunities to develop exactly that mindset. And we'll hear how one nurse used his role to develop this critical thinking, leadership, and provider mindset before even starting his CRNA program. Today's guest is Brandon Bruckner, a new SRNA whose experience as a critical response nurse at a Level 1 trauma center gave him a unique opportunity to think like a provider. In this episode, we'll explore how the critical response nurse's role helped shape Brandon's critical thinking, provider mentality, and preparation for CRNA school, and why experiences like these help many aspiring CRNAs develop skill sets far beyond the bedside. Welcome to the CRNA Mentor Podcast here, Brandon.

Thanks for having me, Ty.

Absolutely.

Yeah, I'm thrilled to have you here. Uh, another one of my colleagues that, uh, joined me on the podcast. Uh, it doesn't get much better than that.

We're going to get into quite a bit here.

Uh, aside from you just starting anesthesia school at the University of Scranton, um, I want to know a little bit about your background. So, so let's talk about, you know, when you got into nursing, uh, where did you start?

So I started at Wilkes University, uh, back in 2017. I graduated Wilkes University in 2021, and that's shortly after that is when we met each other. Uh, found myself right into the operating room out of, uh, Wilkes. And from there I got to meet a lot of the CRNAs, got to see how the job goes down.

And after talking to some people, uh, wanted to go get my experience upstairs, took my way upstairs to the ICU for another 2 years, worked bedside, and found myself into this critical response nurse role for the last 6 7 months, and it's really helped me out getting into school.

Yeah, no, that's great. I, uh, I know I was one of the CRNAs kind of in your ears, like, Brandon, you got to go back to school here, buddy. And I know you've had some, some other, you know, big players in your life that are CRNAs as well, and, and, uh, it helps when there's somebody kind of in your ear. It's like, come on, let's, let's go. I know you're interested in it, so go check it out. How did you kind of find your way into this journey, uh, to become a CRNA, aside from people like myself?

Uh, when do you kind of first realize this is the path I want to pursue?

So while I was in the OR, I really loved my time down there. Being a nurse in the OR was, I will say, better than my time in ICU from the job standpoint. I loved everyone down there, I loved the environment, and that's kind of what I'm looking forward to, getting back to that environment. But working down there, it seemed more surgeon-oriented.

I didn't feel like I was really in the OR for the patient. Uh, great team collaboration skills, got to work in the interdisciplinary team, but it didn't really feel like I was the one really helping the patient. Seeing the way you guys advocate really got that mindset in me, and that's when I wanted to really go to the ICU, get my experience, get all the hands-on work, get the critical thinking experience, and kind of push my way forward into this program. And yeah, like you said, all the people in my ear. I've had my soon-to-be mother-in-law in my ear. She's also a CRNA.

Yep. That's who I was referring to. I was waiting for you to say it here first. Uh, and, and congratulations, uh, wedding coming up here soon.

Yep.

Awesome. Awesome. Uh, Brandon, for our listeners today who have never heard of a critical response nurse, uh, what is that exactly?

So what we technically are, we're a hospital-wide resource. One of the primary things that we're doing is we're responding to traumas. As a Level 1 trauma center, we see them flying through the doors all the time. We have Level 2s that are penetration wounds less than 1 inch. We have traumatic car accidents. We have traumatic arrests. We're responding to rapid responses throughout the hospital, whether that be a family member in the lobby, family member in a room, patient on the med-surg floor, patient inside procedures. We're getting TigerTexts from a lot of the nurses on the floors.

Sometimes they have questions with medications they've never administered. Sometimes they have hands-on skills, need help with IVs. Need help with exchanging suprapubic catheters.

Those are more of the exciting parts of the job.

What we'll do, we'll round every morning, try to round every 4 hours, get to meet with the charge nurses, find out who the critically ill patients are on their floors, some of the patients that they just don't like the way they look, kind of are worried about on the lower levels of care. But ultimately what we're trying to do is prevent upgrades in the hospital and kind of facilitate the flow.

Sometimes we'll be able to get to the floor to start some interventions that'll help de-escalate levels of care and kind of keep them where they're at and ultimately not take the patient to these higher levels of care.

Mm-hmm.

Yeah. One of the things, as you're kind of describing this role, uh, obviously, you know, I, I see you at all these level 1 traumas that we respond to as well with anesthesia, uh, the code situations I see as well. And, and one of the, the big reasons I wanted to have you on this podcast is I feel like every single time I'm in charge or I'm responding to these as a CRNA, you always beat me there. I don't know how you do it, but you're like Johnny on the spot every single time. And there's, there's been times that like it's, it's like a med surg floor and I, and I, you know, there's a whole crowd of around the door and I finally make my way in and you're at the head of the bed already. I'm like, nice job, Brandon, that's awesome. How do you do that?

Uh, sometimes it's just luck of the draw. Sometimes I'm closer to these locations as I am always throughout the hospital, but One part about the rounding is some of these nurses, they'll say, hey, this patient didn't really have a good night. Blood pressures are getting softer. I want you to keep an eye on them. And then before any rapid responses are called, sometimes, sometimes these nurses reach out to us, hey, can you come over, you know, set your set of eyes on this guy? Let me know if there's anything that you would recommend that we could do before kind of escalating care, calling that rapid, getting the hospitalist. Exciting, getting more people involved.

Nice. This, I feel like it was a similar role a couple years ago called like a RIC nurse, and that's like a resource ICU nurse. Is this like a newer role within the hospital?

So what we kind of did was we expanded. I was never, I wasn't there for the RIC nursing itself, but from, I actually talked to some of the nurses there today, kind of wanted to get their background on what it was when they were calling it the RIC role.— and it was more local to the intensive care. So these RIC nurses were more how you were mentioning earlier in the podcast about, um, do you stay in the ICU?

Are you kind of throughout the hospital? Where do you find that your home base?

As the nurses, they were more oriented into the ICU, whereas the critical response nurse, we're trying to make it more hospital-wide.

So Brandon, walk us through, uh, you know, a typical day as a critical response nurse. Uh, you know, obviously you're not bedside, you know, thinking of the normal routine that most of the ICU folks are thinking of, but walk us through your day-to-day here.

So I would like to start off by saying no two days are ever the same in this role. Some days, like when you're bedside in the ICU, you get your pass back, you're used to the patient, you know what's going on. Every morning we come in, there's all new patients throughout the hospital. So I'll come in, I'll clock in.

Typically what we like to do is we'll get report from the night shift RICs, kind of find out who's in the hospital that's kind of on the sicker side. Who they called our RTs on that didn't get upgraded, people we should round on, any traumas that came in, any codes that happened.

We like to talk about the new admissions that came into the ICU that night.

Mm-hmm.

Other days, we may be at a trauma already.

I could be clocking in and my night shift RICs aren't there in the unit.

I'm trying to track them down throughout the hospital to send them home. From that point, we like to do our rounds. We like to do every 4 hours after we kind of rounded on those critical patients. We have a list through the computer that kind of will align people with their vital signs, their age, their unit, any medications they're on. We can round on them, see what's going on with them, see if the nurses need anything with those patients. Round, respond to any TigerTexts, and the rest of the day is just waiting for calls, waiting for traumas, waiting for codes. You never know.

Yeah, that's, that's great. And for those who don't know, one of the paging systems that we use, it's on our phone, it's an app, it's called Tiger Tex, and that's what he's referring to here. Brandon, you talked about this, you call them hawk rounds, like the falcon. Tell me a little bit more about that and why this process is so valuable for you.

So these hawk rounds, I'll say, are more beneficial for the night shift RICs, for our night shift swing doctor. So during the day, we have 2 intensivists all day in the ICU. They're doing their rounds, they're seeing their consults, Our swing doc, depending on who they are, some of them are early birds. Some of them get in there at 3:00 PM, very helpful checking on the Hawk Rounds. Some of them come in at 5:00, but what the Hawk Rounds really do is sometimes we'll have a patient, they call an RRT on them, they stay where they're at. No consults get placed. We could add them to the list, let that swing doctor know, hey, they called an RRT on this patient. They were hypotensive. They didn't upgrade, but just so you know, maybe you could check on them if you have some time. This kind of puts people on the radar that aren't on the radar from the other hospitalists that the ICU doc could be made aware of if we're running short on beds, just so they have in the back of their mind people that could decompensate.

Gotcha. Now, when we spoke before, you said, um, you, you as nurses, you and, uh, it's, it's you and maybe another, um, team member, or you kind of round together is just nursing, right? Is it, is it with an intensivist as well?

Uh, no. So when we're rounding, it's usually day shift. It's the two of us. Sometimes it's just me. All depends on the day, call-offs, staffing.

Nice. How often would you say you're, you're kind of identifying these patients that are, they look like they're kind of starting to head in this wrong direction and you guys get there, uh, maybe before this rapid response or RRT is called?

It does happen pretty often. Um, I would like to say once a shift, but Some shifts, sometimes you go on those streaks, not really too much is happening in the hospital. Sometimes there'll be 5 patients, you're walking down the hallway and people are struggling to breathe that you just kind of walk in on and say, "Hey, could we get some help in here?" What I will say is, speaking back on like how nurses will come on and will come in and they'll text us like, "Hey, can you come set a set of eyes on this patient?" And we'll come in the room and we might be that person to be like, Hey, you're right. I don't really like the way this patient looks. I don't like the way this patient's breathing. We're still hypotensive. We're not really responding to fluids. Maybe we need a medication to help our blood pressure.

Maybe we could get someone else involved. And I'll be the one, I'll Tiger text our intensivist like, hey, I added this person to the hot rounds. Maybe you could come over and check them out and we might need to upgrade them.

Nice. Yeah, we discussed this before we went on air and I'm fascinated with this. One, because it's a dimension of this role I was unaware of. I just think you're just running around going to codes or rapid responses, but to be this resource for these nurses that are like, hey, and honestly, I think of like new nurses on these different floors. You guys are way more accessible, probably more approachable and less intimidating as fellow nurses to bounce some of these ideas off of. And I think that's probably a tremendous part of this role. What is your take on that? I mean, I know you probably get quite a few pages, but—

Yeah.

It's a nice recognition.

Yeah, and I will say the one part that is very beneficial, I feel as though sometimes we're a bit more receptive to the providers themselves too. Sometimes nurses will text us and be like, "Hey, we're trying to escalate care and the doctor's really not answering us." Sometimes I'll shoot 'em a text, they'll answer right away. I had an instance today, we had an RRT on a patient, we got to the floor, they were bleeding from an operative site. We're holding pressure. I walked in, I'm very familiar with the hospitalist that's on. I was like, hey, I'm gonna go grab a bag of fluid while we don't have any blood right now. I'll go grab some fluid. We're starting to get hypotensive. How does that sound? Gave me a quick okay verbal order and we kind of got things moving. It helps things run very smoothly. You know, we're all on the same page, getting familiar with those doctors.

You know, aside from getting familiar with the doctors, you know, this, you're repeatedly assessing these unstable patients. Has that kind of led you to trust your clinical instincts, especially getting these like snapshots of these patients?

Yeah, I will say the confidence that I've gained, obviously I'm still not too, too confident. I don't wanna ever say I'm overconfident, but I've gained a lot of confidence in my position over the past 6 months. One example that I like to use is when I first entered this role, If we have a big code, a big trauma, we like to do some debriefs. And at that time, when I was still new to the position, I would often walk away and really not have any input on what could have gone better, what we could have done. But after doing these experiences, having seen similar, not the same instances over and over again, I feel like I could walk away from a lot of instances and be like, maybe we should have done this. This could have gotten better.

Sure. And that's an important part of it is really reflecting on those experiences. Brandon, everything that you're describing is really the theme of this entire episode is really learning how to think like a provider. And we talked about you assessing patients. I have almost like this FOMO that I didn't have this experience when I was going through my hospital and my ICU, because it seems like some of the things that I absolutely love about anesthesia is all this interdisciplinary interdisciplinary communication, talking to cardiologists, talking to intensivists, trying to guide the patient's care, especially in the anesthesia world, trying to align maybe an MRI and a surgical case so it kind of flows, or we have a crashing patient in endo that we have to bring over and we're trying to ensure that's all kind of smoothed over. But the rapport and stuff that you're building with a lot of these docs and team members, I think is invaluable. Yeah. Do you find yourself asking kind of different questions now that you're in this role than when you were a kind of traditional bedside ICU nurse?

Absolutely. Now that I'm in this role, I kind of see myself in more of the anticipation standpoint. Oftentimes any of these traumas that come in, rapids that come in, codes that are happening, I'm trying to think about what's gonna happen next with what I'm doing. We're giving these meds, we're doing these interventions, but what should I be expecting that I'm gonna be doing next? As an ICU nurse, I saw myself at the bed and I felt at least myself a little bit task-oriented. I'd get report, I would know when I need to document these times, I know when I need to give these meds, I need to roll my patient every 2 hours. A lot of times, this, that, right to the point.

Whereas now I feel like it's very free-flowing.

That's great. I mean, and I really, I talk to obviously so many people along this entire journey. People that are just brand new in the ICU. And you have to break this mold of being so task-oriented. And I feel like it's the nature of nurses.

It's right.

It's, it's the way the shift flows. And, um, sometimes when you have a wrench thrown in the middle of it, then it messes everything up. And then in the back of your mind, it's like, I gotta, I gotta catch back up to where I was supposed to be at. Uh, this role has, allows for this, uh, kind of one, the autonomy that you have, and two, it's kind of less responsibilities that are hampering your critical thinking or hampering your decision-making because you're responding to all these emergencies in real time. Can you think of a particular situation maybe where you were starting to anticipate interventions before other providers arrived?

Absolutely. So one thing that I will like to talk about is Sometimes we'll have RRTs called on patients. We'll get there. I take my long walk across the hospital and I'll ask the nurse, hey, what's going on? And they'll just give us the symptoms. They're saying, hey, this person's speech has been slurred. We're having some weakness. We're going to wait for the provider, you know, see what they want to do. Sometimes in those instances, I grab the wheelchair, I grab the stretcher, and I say, let's get this person to ED. I'm thinking stroke alert. I want to get them as quickly as possible into that CT scanner and get all these interventions done in a timely manner. Usually for these hospitalists on the RTs to, you know, kind of see what we want to do, what orders we're going to get, where we're going to go. But in certain instances, I just think that time is more valuable and I'd rather this patient get right to the ER.

It's great. You're able to kind of have that autonomy and make that decision. You know, we just got to go now. Um, I alluded to this earlier. I want to pivot and kind of talk about some of these kind of hidden benefits of this role. Uh, and it really, in my mind, you know, thinking about exposure to working with these intensivists, uh, working with the trauma surgeons down in the trauma bay, uh, the emergency docs that are down there and some of these advanced practice providers, what have you learned by just simply interacting and observing them?

One big thing that I learned is seeing all these different providers, seeing the way that everything is run, everyone does everything different. And learning that that's totally okay, I feel, is a big part of it. You're gonna be in instances where you're with this provider all the time, you know exactly what they want. You go to the next person and everything's completely different. But ultimately we're all striving for that same outcome. You know, stay calm in these instances, closed loop communication. And as long as we're prioritizing care—

Yeah, no, I think that's great. And I, and I certainly see it myself. And I feel like it's also kind of like part of anesthesia school. It's like you get to pick and choose all these things, uh, and, and maybe approaches and treatments and just the way that you carry yourself. I know that there are some docs down, down in our, uh, in the traumas that I'm like, man, I, I want to, you know, interact that way with my team. I want to, you know, have this, this clear thinking and this provider mentality, uh, and carry myself just as they do. So you get to, you know, see that time and time again, and you start to, you know, piece the puzzle together, I guess, as a, you know, thinking as a provider. Um, have you started to notice some of the patterns, I would say, when you're work with these providers time and time again.

Yeah, I will say from both a provider and a patient standpoint, some doctors, I know the way they like to go about things. I'm sometimes ready for their next order. I'm grabbing medications and they're like, "Hey, could we do that?" And I'm behind them with it. I have it in the pump, I have it loaded, ready to go.

So I think you're exactly right in terms of, you know, noticing, almost anticipating this next step. And it's, You know, in the operating room, we see these surgical techs that are teaching. They're like, you need to know, be like 2 to 3 steps ahead of the surgeon. You need to be handing them what they need before they actually need it. And that sounds like exactly your role in some of these traumas. What have you learned from watching some of these different physicians that lead these high-pressure situations?

The big thing that I've learned is staying calm in these stressful environments. Oftentimes we go to these traumas, we go to these codes, there's 20, 30 people It's important to really make sure your communication's heard, make sure people are understanding what they're doing, and we're prioritizing care for that patient. Ultimately, sometimes there may be too many people. Sometimes there's a lot of talking. Sometimes there's a lot of chatter, but we're all there for the same goal.

So that leader really needs to step up, make sure they're heard, control the situation, and do what's best for the patient.

Yeah, I, I couldn't agree more. And, and you know, I'm trying to, to, to parallel these two and, and this is the perfect segue in terms of, this is exactly what anesthesia is. This is exactly what the operating room is. You know, being able to remain composed, to lead during emergencies, to have this closed-loop communication with the surgeon or the anesthesiologist or the other team members in the operating room. And, you know, these similarities are why this role, in my opinion, is such an asset to people like yourself that are getting into anesthesia school and already having all these experiences under your belt. Are there concepts in anesthesia that feel more familiar because of your experience in these emergencies? I know you haven't set foot in clinical yet, but you've been in the operating room as an operating room nurse. Can you see how that kind of translates?

Yeah. Um, sometimes it's the minor things, uh, airway management. Some of these RRTs I go to, uh, they'll say, hey, our patient's hypotensive, or we were on 2 liters nasal cannula, we're on 6 now, we're not breathing well.

And the patient's sideways in the bed, you know, getting the proper position, getting their head up in a good position to breathe.

Another concept that happens quite often is the hemodynamics when we're intubating these patients, expecting that hypotension sometimes when we're pushing these induction meds. Oftentimes now when I'm grabbing the RSI kits for our doctors, I'll grab that Neostig just in anticipation, kind of looking ahead.

Another point that we could speak on is acid-base physiology that I was just covering on some of my PowerPoints. I have an instance from a couple weeks ago, maybe a week ago. We were coding a patient on the floor, quickly started norepinephrine, quickly started epinephrine, and the patient's pressure wouldn't budge. Drew an i-STAT, her pH was 6.7. We started giving them bicarb and our pressure started to work. So it's, it's those smaller concepts that I'm just now getting into, just now touching the surface on.

Brandon, for our ICU nurses who are listening today who have access to a role like this, why should they consider doing it?

Putting yourself in uncomfortable situations. Uh, I will say you're, you're not familiar with these areas on the med-surg floor, in IR, in endo, a lot of places you aren't typically at. You don't know the resources, you don't know the people. Being able to use what you have around you, who you have around you, and reach out to get these resources, I feel like is very valuable.

But getting in those uncomfortable situations, I feel is very beneficial when you don't feel the most comfortable, the most confident, that's when you learn a lot.

Yeah, I couldn't agree more. And there's so many, again, so many parallels with anesthesia with this, but you know, for those who are not super aware of roles as nurse anesthetists that are listening today, we give anesthesia outside the OR, multiple different locations. And you don't always have the best backup, the best help. It's not always super accessible where you're at. Sometimes there's parts of the hospital where you're kind of in no man's land. Sometimes there's parts of the hospital where you don't have great service on your phone, and even trying to get help is difficult, you know. So being able to kind of go all over the hospital in this type of role opens the door to those experiences, and you're going to feel that much more comfortable when you're a CRNA in these situations. Um, Brandon, you know, I think it's important as we talk about all these benefits, all these cool things, you know, associated with this role, let's talk a little bit about some of the drawbacks. Because, you know, with anything, there are things that are not as, as great about this role.

Yeah, uh, the one con that I saw when I was debating if I wanted to take this role or not is you don't get to see that trend of the 12-hour day. You know, following the trends is very big from what I was looking at when I was doing this research, if I wanted to stay as an ICU nurse or a critical response nurse, looking into applying for those CRNA schools. And trends are very important, you know, seeing how a patient progresses or declines over a 12-hour shift. You don't really get that. Uh, you get those little bits, those little increments. You're with someone and then you're gone.

Mhm.

And then another con, as we kind of talked about, you talked about our autonomy, you talked about us kind of doing things before providers get there.

Sometimes people expect that and it puts us in uncomfortable situations.

Uh, I've had people in certain instances in the trauma bay and procedural areas, they're just like, oh, hey, don't you have like your goodie bag of sedation pressors? Whereas we can't do that. You know, we need orders and that's just how things are.

Right.

Yeah. No, I think that's important to point out. And, uh, I'm going to put on my, my mentor cap here for a second, you know, for So for anybody that's listening today and is super inspired by Brandon's story, uh, and you're looking for these roles in your hospital, the number one thing that you need to do is identify your target schools and see if this is okay with them. There are some CRNA programs that are out there that want you to stay bedside and, and will actually look at this role and be like, actually, you know, we want you bedside. It's easier to compare, uh, you know, our— all of our applicants who are bedside. We wanna see maybe that trend in care and taking care of these patients, as Brandon mentioned. So, you know, before you get all excited, take this next role that opens up in your hospital, might be worthwhile reaching out to your anesthesia programs or in the very least attending their information sessions. You could ask questions there and really ensure that, you know, everything's aligning for the schools that you are targeting here. Yeah. Brandon, looking back, do you think that this role gave you an advantage getting accepted to CRNA school?

Yes, I find myself doing things that as a floor nurse I would have never done, and some of these skills I feel would be very, very beneficial moving forward. Um, the use of ultrasound IVs, you know, getting my hands on the ultrasound, getting ready for those A-lines, getting ready for those central line insertions, networking with those unfamiliar people. Like I said, you meet new faces that you just see, you get more confidence in speaking to someone who you just met for the first time. Um, I feel like another big part that's very important looking into school is a lot of these patients that I'm responding to, I don't know their background. I don't know their health history, and I have to treat it anyways. You know, I don't get that full report.

I don't have a full assessment.

I don't have all my scans. I don't have all my labs, but the job's still got to be done, and I need to do what I can in that moment.

That is a gem there, Brandon. And that's something that I know a lot of our super Type A ICU nurses are like, well, I need this, I need that, I need that. But it's, you know, responding to emergencies, whether that's ICU, whether that's anesthesia, that piece of advice and that perspective is really, that's what you're gonna have and that's what you're gonna see. And you just have to adapt. And that's part of anesthesia school. So yeah, great perspective there, Brandon. As we wrap this up, you know, if you could go back and give yourself any advice as an ICU nurse preparing for CRNA school, uh, obviously knowing everything that you've learned through this role, what would you tell yourself?

What I would have told myself is all the hesitancy I had looking into this role, leaving bedside, I would have done it earlier. I feel like these last 6 months I have taken so much in. I have learned so much. I have seen so much. I have worked with so many different people that are going to be very beneficial down the road. I took a lot out of this role, and I feel like it was very beneficial for my SRNA career.

Yeah, no, I, I love that, Brandon. And, you know, for everybody listening today, I think one of the biggest takeaways from this episode is that becoming a CRNA starts long before your first day of CRNA school. And if it's available at your hospital, this critical response nurse role, it can help you develop critical thinking, leadership, situational awareness, and this provider mindset.

But, but the real lesson isn't about a specific job title. It's about seeking experiences that challenge you to grow as a clinician and expand the way you think about patient care, because the transition from nurse to provider is built on one experience, one patient, and one decision at a time.

Brandon, thank you so much for sharing your perspective and this role that, that you currently have, uh, in conjunction with starting CRNA school. I really appreciate you being here today. And to everyone tuning in to CRNA Mentor Podcast, As always, if you found this episode to be helpful, share it with somebody who needs to hear it. All right, thank you for joining us today, Brandon, on the CRNA Mentor Podcast. I appreciate having you here.

Thank you so much for having me, Ty, and best of luck to everyone in their future CRNA journey.