A nurse I was orienting asked a question that stopped me.

“Why do we have to wait for a current type and screen before ordering red blood cells, but not platelets?”

It was the kind of question that should have a clear answer. She wasn’t new to nursing, just new to our unit, which made it land differently. This wasn’t inexperience. It was a fresh perspective on a practice I had stopped questioning.

I had a general understanding. I knew that red blood cells carry the antigens most likely to trigger clinically significant antibody formation, and that ensuring compatibility before transfusion is critical. Platelets, by comparison, are less likely to require the same level of matching in routine situations. But when I tried to explain it clearly and completely, I hesitated.

My first instinct was to simplify the answer: “That’s just how we do it.” I paused before saying it out loud. Although the practice made sense to me, I had never examined it in a way that I could confidently teach, explain, or connect back to policy.

The question exposed a gap between practice, policy, and understanding. It also raised something larger: how often do we follow practices we can’t fully explain, document, or defend?

This experience highlighted a broader issue in nursing practice: we often teach what to do without fully teaching why.

When practice and policy don’t match

We decided to look into it together. We started with our policy and procedure. The answer was not there. We reached out to the blood bank, spoke with our educator, and discussed it with colleagues.

What we found was that the practice itself was sound. There were valid clinical reasons for the difference in timing between red blood cell and platelet orders. But those reasons were not clearly reflected in our written procedure.

The question led to a change. Our procedure was updated to better align with actual practice and the clinical rationale behind it. More importantly, my understanding changed. What began as a simple question became an opportunity for meaningful learning for both of us.

This experience also shifted how I approach precepting. In busy clinical environments, it is easy for practice to drift toward habit. Over time, workarounds and informal norms begin to feel like standards. Nurses entering a new unit, even those with years of experience, are often the first to notice the inconsistencies. They ask the questions others no longer think to ask.

How we respond to those questions matters. If we default to “this is just how we do it,” we unintentionally reinforce the idea that practice does not need to be understood, only followed. When we pause and engage, even when we don’t immediately know the answer, we model something different. We show that uncertainty is not a weakness. It is a starting point.

What we do versus what we can show

I saw a different kind of questioning in a situation involving transfusion documentation. New nurses I was orienting would often ask what it meant when a product was labeled as irradiated. It was a good teaching moment, but over time, a deeper issue became apparent.

In practice, we were administering both irradiated and psoralen-treated blood products, which achieve similar outcomes through different processes. However, in our electronic health record, the only documentation option available was to indicate whether a product was irradiated. There was no way to accurately reflect what we were actually verifying at the chairside.

That discrepancy made me uncomfortable. It felt like we were doing the right thing, but not fully able to demonstrate it. Documentation is how clinical judgment is made visible, showing that the right product was verified for the right patient at the right time. If we cannot document what we actually did, we cannot fully demonstrate that we provided safe care.

When the system does not allow us to document accurately, it creates a gap between what we do and what we can show. That gap matters, not only for patient safety, but for professional accountability and the ability to stand behind our practice.

This was not just a limitation. It was something that could be changed. The documentation options were eventually updated to include psoralen-treated products, allowing the system to better reflect actual practice.

That experience reinforced an important point: nurses do not just work within systems. We can improve them.

Teaching nurses to think, not just follow

These experiences shifted how I approach teaching. When I orient nurses now, I still teach the standards and review policies and procedures. But I also acknowledge something that is not always explicitly acknowledged: practice, policy, and rationale do not always align perfectly.

When they don’t, the most important skill is not memorization. It is reasoning.

I encourage nurses to ask questions, not as a challenge to authority, but as a commitment to understanding. Because the goal is not to create nurses who follow steps. The goal is to develop nurses who can explain what they are doing, recognize when something doesn’t align, and act when it needs to change.

In complex clinical environments, policies can lag behind practice, and systems may not capture clinical nuance. In those moments, it is the nurse at the bedside who is best positioned to see the gap. Often, it is the newest nurse who sees it first.

Experience builds efficiency, but it can also normalize inconsistency. We begin to rely on pattern recognition instead of active reasoning. New nurses haven’t developed those patterns yet. They notice what doesn’t fit. Their questions can feel disruptive, especially in fast-paced settings, but they are often exactly what the system needs.

Closing the gap

That initial question about transfusion timing did not expose a problem with practice. It exposed a gap between practice, policy, and explanation.

Closing that gap required curiosity, collaboration, and a willingness to re-examine something we thought we understood. It also reinforced something I now consider essential to nursing practice.

Safe practice is not just about doing the right thing. It is about understanding why it is the right thing, being able to explain it, and ensuring that what we do can be clearly documented and supported.

The safest nurses are not the ones who never question what they are taught. They are the ones who understand it deeply enough to ask why and act when the answer does not align.

Courtney Desy, BSN, RN, OCN, is an oncology infusion nurse. She cares for adults receiving chemotherapy and immunotherapy and is the founder of the Stronger Than Chemo Foundation, a nonprofit focused on improving patient education and support during cancer care. Her last post on AJN Off the Charts was “How to Keep Caring Without Breaking.”