how do you build critical thinking skills? how do you become an independent decision maker? how do you make confident decisions in the clinicals? how do you apply the knowledge you learned in theory into the real world? how do you just look more confident?i have self esteem issues, does anyone know where i can boost myself self esteem/confidence and i think it really gets in the way of my decision making. how do i overcome this? please help.

First, I want to say that you're already on the road if you're asking the questions that you asked.

I think you just need some time and experience. In my opinion, critical thinking is partially based on a skill we all possess to some degree and partially based on experience. It's truly a learning curve. I think to be a good critical thinker you have to a good base in pathophysiology while at the same time understand that every patient is an individual and reacts and responds differently.

For me, I never fully grasped a disease process just by reading about it and taking a test on it. Until I encountered a patient with a certain condition it was very difficult for me to put the whole picture together. I've been a nurse for 10 years, and I feel very confident in most of my nursing skills and decision making, but not a days go by that I don't question myself about something I encounter.

I guess what I'm saying is that lifelong learning and continuously adding to your knowledge base will lead you to that critical thinking and decision making process. You're doing great - it just takes time!

I agree with roosmom most of your concerns will be resolved with time and taking care of patients with different diseases. Are you still in school? If so, get the most out of your clinical time. Get into the pt charts and look at test results, labs, progress notes (if you can read them), PT/OT notes, ect. See how you pt disease has progressed and what tx where used. If the nurses have time ask lots of questions and help with pts that are not yours.

Most of what you know as a nurse will be learned on the job, so do not feel like you should know it all when you get out of school.

Confidence and self esteem come from having achieved things that give you reason to have confidence in yourself. So don't focus on the self esteem and confidence as they will come with experience and success. Confidence and self esteem are the result of hard work and success more than the causes.

Focus on learning factual information (about diseases, meds, communication, etc.) and then take a deep breath and start practicing. When you read or hear a fact, ask yourself and others, "How would that appear in a patient? What would you do with that information in the clinical setting? etc." Don't just memorize the information, immediately ask yourself (and others) how that information would be encountered and used in the work world. If you do that each and every day, you will start to think of the information in context, not as a series of abstracts facts and concepts. That will make it easier to apply the information in clinical ... which will boost your confidence as you see that you can be successful.

Time.

Experience.

Willingness to be TAUGHT.

ASK questions constantly.

Yes, I know these are simple answers....

I can't tell you how to become more confident. I can tell you that you have been taught critical thinking skills all of your life and "critical thinking" is not just a nursing process. Word problems, horrible math problems about two trains, even social situations has tested your critical thinking abilities.

When it comes to nursing or anything else, basically it all boils down to the: who, what, where, when, why and how of questions/answers. Do you have all of the pertinent information to make the right decision?

Some tricks that I used with my orientees.

1. When you walk into a patient room for the first time (not your assigned patient), in 30 seconds how much information can you tell about the patient. (You can do this at the mall or any public place, too). A cane at the bedside may indicate mobility issues, etc.

2. When you give a medication know not only what the medication is (class), but really what does it do? Why are you giving it? What is the benefit of giving it? What is a potential consequence of giving it? What are you going to do if this occurs?

Metoprolol is a beta blocker. It reduces heart rate and demand for oxygen. I am giving this to my patient because he has a history of CHF and beta blockade also inhibits remodeling of cardiac tissue. It may potentially cause bradycardia or hypotension. I need to check blood pressure. I also need to know what base line blood pressure is. If the patient does have bradycardia or hypotension and are they symptomatic where I may need to perform external pacing or give fluid boluses. How long can I expect these symptoms to last? Is my patient going to need a pacemaker.

3. Any time you have a patient with an unfamiliar medication or diagnosis take 5 minutes and look it up. It will really help you in the long run. Then you will be able to connect the information that is in a book or article to the person lying in the bed and it will help you remember.

All of this comes with time. None of us became experts without having a few trials and tribulations ourselves.

Time, experience, watching others, having a bit of a thick skin to take criticism. Sometimes criticism is well deserved, but not delivered kindly. Remember what was said (if it was valid), not necessarily how if it was delivered unkindly. It can be hard to build confidence because others are often not nice, but really that is life. Rise above the snide and sincerely try to learn to do what you need to do and learn your best. No one, no one did everything right when they first came out of school or were in school. If they tell you they did, they are either a liar or sufferring from dementia. Don't miss the activity "at the side of the road." You may not learn so much about the heart from your chf patient today as you do about dealing with his anxious family or seeing his physician model how not to talk to a patient. Always have a wide view and check the periphery often for what is going on around you, but be "in the zone" when you need to be. Always be careful and think before you speak when rushed or angry. It could be your child in that bed or he/she could be that new nurse who is plucking someone's nerves many years down the road. Good luck! It will come in time. I am sure there are many who would be surprised that I haven't been demoted to dietary aid yet who knew me 20+ years ago as a new grad.

You will get there eventually.

One day you will be on the floor and you will have a light bulb moment. Once you get that first one its light bulb moments for a while. I like to think of it like changing gears. It takes a second to switch and then it works perfectly.

My light bulb moment came when I gave an old man 4 popsicles. He was a diabetic. After that incident, I started connecting one and one together. I started seeing more cause and effects type of things.

Just don't be hard on yourself. you will get it, when you get it.

These are timely questions, because a couple of my newer co-workers are going through the same issues, and I would really like to be able to help them along. I've seen them both--caring, hard-working nurses--shoot themselves in the foot through lack of confidence, and I can remember doing some of the same stupid things just a few years ago. Plus, I'm learning to do charge, now, so I'm facing some of the same challenges they are, in a way, except that I've already survived my first year as an RN, so confidence isn't as much a problem. (If you can get through that first year, you should pretty much be able to get through anything. I still sometimes find I'm not entirely sure what I'm doing, but it has been awhile since I've felt like I couldn't either figure it out or find someone who could. Knock on wood.)

I think the two biggest obstacles to critical thinking are panic and the simple, ordinary mechanics of the job. Back in clinicals, all those many months ago, when I passed a med, I could tell a patient what it was, why they needed it, what the side effects were, yada, yada, yada, then I'd struggle to get the package open. And then, maybe a fourth of the time, the patient would have been taking the med for something off-label for a couple of years or more, and they'd tell me why they were really taking it. Well, you know, that still happens, now and then. I'd been a nurse for a couple of years when I had a 10 yr old (or so) seizure patient getting clonidine. Uh-oh, look-alike, sound-alike!!! Paged the doc, pronto, and found out clonidine is sometimes prescribed for behavioral problems--ADD, if memory serves. Told the mom why the med was late and she laughed and explained it to me better than the doctor had. But, of course, I'd lost all hope of ever being Supernurse, by then, so it was just a learning experience, and not a crushing blow to my self-image.

So, anyway, I think a big part of critical thinking is just a matter of getting better at the nuts and bolts, so that you have the time and available brain cells to look at the big picture. I guess it's a lot the same with confidence, although I do like the saying "Fake it until you make it." Not meaning fumble along blindly, but there's a big difference between, "I'd better get some help!" and, "I think I'd like to get a second opinion, before we proceed..."

I don't know how well I'm explaining that. That's the big problem I'm finding with my new friends--it all makes sense, once you've done it, but try to put it into words and it's practically jibberish.

ETA: One of the things I used to tell myself regularly, and still do from time to time, is: If they wanted a good nurse, they could have hired one. It sounds terrible, and I really am grateful they were willing to take a chance on making a good nurse, rather than buying one ready-made. But I truly believe I took a lot of non-productive strain off my brain when I learned to aspire toward becoming marginally competent, rather than great. Mind you, I'm not giving up on great, but it ain't gonna happen overnight, or in four years. I'll be happy, now, if I can be a really good nurse while I'm still ambulatory.

Time.

Experience.

Willingness to be TAUGHT.

ASK questions constantly.

Yes, I know these are simple answers....

Short and sweet and oh so true!! I totally agree, couldn't have said it better.

learn the nursing process and what goes on in each step. always ask why and keep seeking the answer.

• http://home.cogeco.ca/~nursingprocess/index.htm - the nursing process & critical thinking.
  
• http://www.mac.edu/faculty/nursingdepartment/200%20level/nursing_process.htm#return%20to%20top - the nursing process – a short introductory tutorial
  
• http://www06.homepage.villanova.edu/elizabeth.bruderle/1103/nursingprocess.htm - the nursing process