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What Educators Can Learn from Airline Pilots to Help Students Think More Like a Nurse

By March 8, 2018February 1st, 2019One Comment

On a recent flight, I sat next to a pilot who was in training for a major airline. As we talked, he shared something that intrigued me as a nurse and nurse educator.

He discussed the importance of safety and the use of checklists that are done not by memory but are written down for the pilot, even if they have years of experience. To maintain a high standard of safety, each flight is never routine and the importance of identifying four key milestones of each flight with each milestone having its own unique checklist.

This has been found to be an essential component to prevent the plane from a needless crash.

On the pilot steering wheel of the image of this blog post are the four key milestones for every flight and a correlating checklist to ensure safety:

  1. Before takeoff
  2. After takeoff
  3. Approach
  4. Landing

Failure to methodically complete each correlating checklist can result in a crash with devastating consequences. Though routine, recognizing the importance of each phase and resultant checklist are essential to airline safety. Though you are more than 30,000 feet off the ground, it is ironic that commercial flight is safer today than traveling on the ground by your motor vehicle!

As I reflected on my own nursing practice, these four key components of a safe flight have a correlation to safe patient care that the nurse provides with a correlating checklist that an experienced nurse typically internalizes.

To help students be safe in clinical and think more like a nurse, identifying these correlating four milestones of patient care with its resultant checklist can help students to think more like a nurse.

Four Milestones of Patient Care

It is ironic that both pilots and nurses have the same consequence when safety is compromised or needed checklists are incomplete; the loss of innocent human life. For pilots, it is an unnecessary crash.

In nursing, the literature calls this problem failure to rescue and occurs when a complication goes unrecognized by the nurse and leads to an adverse outcome including patient death (Clarke & Aiken, 2003).

As a nurse, more than written checklists are needed.

The nurse must be able to know what to do with the information collected and clinically reason to recognize relevant clinical data, current nursing priorities, and interpret the data to grasp the essence of the current situation to provide safe patient care.

As I reflected on my own practice, I identified the following for correlating phases or milestones while providing patient care over the course of a shift:

Four Milestones of Patient Care:

  1. Patient prep
  2. First contact with the patient
  3. Care provided during shift
  4. End of shift report

1. Patient Prep…Clinical Reasoning Questions: Part I

Patient or clinical prep is the first milestone and one of the most important. Failure to adequately prepare and go through the checklist here will impact how data is interpreted when the patient is seen for the first time.

For a pilot, this step is just as crucial. When the preflight checklist is not completely done, it can result in a crash once the plane is off the ground.

In my practice-based model of clinical reasoning of sequential questions, the first eight questions address this first step and provide a foundation for this essential checklist of patient care that begins:

  1. What is the primary problem and what is its underlying cause or pathophysiology?
  2. What clinical data from the chart is RELEVANT and needs to be trended because it is clinically significant?
  3. List all relevant physical nursing priorities. What nursing priority captures the “essence” and will guide your plan of care?
  4. What nursing interventions will you initiate based on this priority and what are the desired outcomes?

To download the remainder of this “checklist” and access a free webinar of Keith explaining more about his practice-based model of clinical reasoning questions, CLICK HERE. 

2. First contact with the patient…Clinical Reasoning Questions: Part II

Once the patient is seen for the first time, the nurse collects clinical data including vital signs, nursing assessment and observations related to his/her interaction with the patient.

This information also can be put into the context of a checklist. The next four questions of my clinical reasoning model address milestone two of patient care that begins

  1. What clinical assessment data did you just collect that is RELEVANT and needs to be TRENDED because it is clinically significant?
  2. Does your nursing priority or plan of care need to be modified in any way after assessing your patient?
  3. Does your nursing priority or plan of care need to be modified in any way after assessing your patient?
  4. What educational priorities have you identified and how will you address them?

Room Safety Checklists

As I reflected on the internal safety checklists I use when I enter the room for the first time, I wrote down just a few that include the following:

  • Look at the patient.
    • Do they need to be repositioned?
    • Assess placement of all tubes. Is the nasogastric tube, Foley, or IV properly secured?
  • Oxygen.
    • Check the flow rate to ensure that what has been charted is flowing
    • Oxygen delivery device is on correctly so the patient is receiving O2
  • Ambu bag.
    • Present in the room and ready to use if needed?
  • Suction Set up.
    • Present and set up so that in case of emergency it is ready to be utilized.
    • If the patient has a nasogastric tube, is suction set to the correct level of low intermittent or low continuous and is it at low medium or high depending on what is ordered?
  • IV pump.
    • IV solution the same that is ordered?
    • Check this against what is in the MAR.
    • IV rate correct? Follow the IV tubing to the patient. Is the IV adequately secured and are there signs of infiltration?
  • Room order.
    • Is this a healing environment or is there chaos instead? Florence Nightingale got it right. Environment matters and it starts right here.
  • Care board.
    • Update care board with name
    • Make sure it is up-to-date?
  • Foley catheter.
    • Is the catheter well secured at the thigh so it does not tug on the urethra and cause unnecessary trauma?
    • Are there any dependent loops in the tubing from the patient? If so use the plastic clamp that should be on the tubing to attach it to the bed so that dependent loops that can increase the risk of infection are not present in urine is draining by gravity all the way to the bag.
  • Blood pressure cuff and cardiac monitor.
    • If the patient is on telemetry and ongoing blood pressure monitoring, is the cuff the right size?
    • Are the leads in the right place. Are patches loose or secure on patient?
  • Sequential compression devices.
    • Properly attached to lower legs
    • Pump is on
    • If not in use, are off the floor

3.Care provided during shift…TREND Clinical Data 

In addition to the tasks including meds to give, treatments, etc. that create their own unique checklist, the nurse must also do one thing to THINK like a nurse while providing care…TREND all clinical data collected…by comparing it to the most recent to evaluate and note a potential change in status.

4.End of shift report…SBAR

Landing a plane is the final step of a safe flight and is never routine.

In the same way, the final phase of patient care ends with shift report which is like a baton handoff in a relay. If the baton gets dropped, things get missed, and the patient is impacted.

Using SBAR for situation, background, assessment, and recommendation is the starting point for a consistent checklist or handoff that the nurse uses to safely complete this final checklist of patient care, but is not all-inclusive so be sure to include more information to tie everything together.

Action Step

Create, or better yet, dialogue with your students to develop your own specific checklists depending on the level of your student and the clinical setting where patients are cared for.

If you have clinical in ICU or other specialty areas, additional checklists are needed for central lines, chest tubes, ventilator/bipap, etc. Be sure to develop these and make them available for your students, but keep it simple with NEED to know safety checkoffs.

In Closing

I am not advocating cookbook nursing and simply checking off a box without thinking and reflecting on what is done by the nurse.

Instead, just as the sequential clinical reasoning questions I developed reflect the sequential steps of how a nurse internally thinks in practice, by creating concrete, practical checklists (something all pilots do to!) with each phase of patient care makes safety checks visible to a novice student nurse.

As a student progresses over time, these nurse thinking questions and checklists become internalized and can be used to help develop the thinking that is needed to ensure that graduates think like a nurse and are practice ready.

Relevant Past Blogs 

Comment Question:
What creative strategies have you used in the clinical setting to help your students think more like a nurse?
Comment below and let the conversation begin!


  • Clarke, S.P. & Aiken, L.H. (2003). Failure to rescue. American Journal of Nursing, 103, 42-47.

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Join the discussion One Comment

  • Merry Bond says:

    I. Love. This. I just forwarded this article to two of my colleagues. I think it would be easy to level it for fundamentals through advanced nursing courses.
    Thank you for all you do to help transform nursing education.

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