Critical Thinking: you have it or you don't. Agree or disagree? - Page 7

"6:04 pm by proud nurse I have been keeping up with this thread, but what about when someone were to use the term: 1. Being able to look at the big picture 2. Thinking outside the box 3. You have to not be so task oriented Is this another way to say someone is lacking critical thinking skills?" I think proud nurse is right! I have always hated that term "critical thinking"! Management and other preceptors toss that term around and new grads are always so afraid of it. I usually tell my orientees to strive for "anticipating" the patients condition and needs or the doctors orders. Or answering the question "and now what?" Maybe I make it too simple, but I don't think it should be that hard either...

You took the words right out of my mouth!

LTC nurse are you a chiver? I ask cause of the avatar.

And I think people either have it or you dont. Its painfully easy to witness too.

Hi LTC nurse11.

What is oversimplified thinking, if someone is said to "have it or not"?


Yea pretty much people oversimplify judging if others have it or not, especially in light of subjective, incomplete, or only partially or clearly set, objective definitions.

The problem, IMHO, in nursing is that there are people coming into things trying to validate themselves or others, or they seek to invalidate others--too often to make themselve feel one-up or superior, or to get some social edge; thus they set forth with judgmental or subjective analyses of things.

They may use terminology such as "critical thinking" in order to rationalize their subjective evaluations of people or situatuions. I have, from day one, had a huge problem with this in nursing. There is too much ego nonsense in healthcare, including nursing and medicine. It's silly and counterproductive. And in general, there is way too much judgmentalism of other nurses, their practices and characters, or even "fit," that causes disunity in the field. People are too quick to throw titles on each other.

I like this business definition of critical thinking:

"Objective examination of assumptions (adopted rules of thumb) underlying current beliefs to assess their correctness and legitimacy, and thus to validate or invalidate the beliefs."


You can think critically about whether a long-held treatment approach is the correct path to use in a particular situation.

I had a kid once that had tracheal edema from an unidentified, presumbed infectious agent. The child had received a good number of IV decadron doses, and was on broad spectrum IV antibiotics. Of course, sensibly, he was explored and intubated in the OR, and this I understood without question. He was on IV sedation, but was on the light side, and was continuing to receive the aforementioned medications around the clock. He awoke and was scared and angry and fighting. He wet the bed a number of times, b/c someone thought to not put a foley cathether in him in the OR. Depending upon how you looked at his situation, you could have fought it either way; but given the current attention to cauti infections, this position could be quite sensible. The cuff leak test is often done to predict the probability of laryngeal stridor. Both parents were nearby and very attentive to the five year old child. My suggestion, although it was somehow grossly distorted and met with outlandish outrage, was to perhaps back off of the sedation a little and allow the child to interact (yes while the ETT was still in) with his parents and try to use the urinal. My position was that he would be moving around, and movement, in light of all the meds he was receiving, may help to mobilize accumulation of fluid as the meds are working, and in time, he might be more apt to develop a significant airleak, without having to keep him ultra sedated on versed and fentanyl. Worst case, if he was too wild and stressed, we could re-sedate until he could be reassessed for cuff leak. The parents were very appreciative of this perspective, and I had worked in other hospitals and seen such approaches work. I hated to think it, but it seemed to me, since the census had been low in that unit at that particular time, they wanted to keep this kid as long as possible. Of course I can't prove that, and I don't want to be unfair. But I have seen a lot over the years.

At any rate, a former adult nurse who had made her in-roads in that unit as "somebody" and the manager's "informant" started a huge issue over it. Now I had had a ton more critical care peds experience than she, but I was trying to keep my mouth shut. I made a possible suggestion, but rather than calmly and critically thinking about the possibility, even if the plan was not going to change, they were drilling me loudly, bringing undo attention, and basically just trying to get me to fight and look like an arse. I stated I shared one perspective, but that it is ultimately up to the doctor, and I am fine with the plan as it is. I just offered another perspective, with the potential to bring the child to the previous level of sedation if that what needed--but again, its up to the team and not me. The point is, even though I was moving on to another patient and other situations, they would not let it go. It was completely intention and was an attempt to undermine me, my thinking skills, and my safety of practice. I never said, "Hey, let's just extubate the kid right now." NOPE. Not even close. It was a well, disguised, bullying game. I had seen it before in other places. I smiled, kept my mouth shut and continued to move on; but the handful of nurses were not going to let it go, and they had the nurse manager convinced that I was some kind of nutjob or something. It was incredibly ridiculous.

At the end of the day, the people that were guilty of poor critical thinking in that situation were the troublemakers. They couldn't conceive of anythink short of sedating the hell out of the kid for God knows how long. When I spoke to the fellow anesthesiologist--their initiation, not mine--he looked at me as if to say he saw my point of view, but the numbers were against him, so he quoted some piece of research from years before and hauled butt out of their. People knew how toxic that unit could be--even anesthesia fellows.

The problem was that they could not think in terms of what was put forth to them, but rather jumped to conclusions about what was suggested. And not only was this poor critical thinking on their part, it was, to some degree, intentional sabbotage. On that day I decided I would work on continuing my education such that I could move out of nursing. That kind of closed-minded and intentionally misconstrued and manipulative thinking made it clear to me why this is not the field for true thinkers in such environments.

Don't get me wrong. I am CERTAINLY NOT saying nurses don't engage in highlevel thinking, and absolutely critical care nurses have to do this on a daily, if not hourly basis in their roles.

It's just too so hard to find the right team of nurses that aren't trying to undermine or outdo each other, but less come together with some sort of unified, "think tank" approach to things. It's like some can't think this way or they just won't. Either way, those that are really into higher level thinking are push down and trampled on by those that can or will not think and discuss, objectively, without other perspectives in mind.

As long as nursing is dominanted by people that refuse to grow or just cannot grow in this capacity, those that have and would use the ability to think with varied and higher-ordered thinking will often be trampled over. Some environments allow such thinking and openness; but too many do not. In over 20 years, I have not seen a great deal of change in this direction. And this issue, at least in part, is the lack of ability for nurses to engage in building coalitions rather than embracing fractions or cliques. Sadly, too many nursing administrations want it that way --that way they can hold on to tigher control of nursing. They control the dominant players and have them limit the others. Again, I have seen this played out over decades.

I am fundamentally against this type of leadership and thinking. Thus, my hope is to be out of nursing in the next several years. I have loved much of what I have done in nursing, and the patients, families, many other nurses and healthcare personnel, and physicians. But the way these kinds of things are encouraged and show no signs of changing, I can't deal with the toxic and limited thinking anymore.

Critical thinking? I like this fellow's perspective on what it is:



-- Daniel J. Kurland


How do you truly develop this in nurses. I mean if critical care nurses buck against this whole realm of thinking, what hope is their for the profession in this regard?

samsadmas8

Nice post, usually I don't read long ones, but you do have an interesting point of view on critical thinking. I teach a preceptor course throughout the US and one of my modules is critical thinking and decision making. I love when I learn new things and my 'take-away' from your post to bring up in future classes is that even seasoned nurses need to remind themselves to see the whole picture and not get stuck in their ways, otherwise, they are not making sound clinical decisions either. To prevent this I actually tell the preceptor not to assign to many 'frequent fliers' to their new nurses because they become too desensitized to the patient's needs.
That is why I believe that to the untrained eye (I mean untrained preceptor or educator who facilitates nursing orientation), "nurses either have it or they don't."

However, as you explained in your post, the nursing culture on the unit can extinguish a new nurse's ability to critical think. To add to your suggestions, I wanted to supply information from a scholar in the arena of promoting critical thinking in nurses. Christine Tanner has been doing research in critical thinking, clinical judgment, and clinical decision making for 25 years. The most significant findings from her research are these:
1. Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation
2. Sound clinical judgment depends on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns (frequent flyers and personal opinion)
3. Clinical judgments are influenced by the context in which the situation occurs and the culture of the unit
4. Nurses use a variety of reasoning patterns alone or in combination
5. Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning

I love her statement that shows that critical thinking in not just basically what to do when, but to become a true master at clinical decision making, you must know how to be even better the next time. Culture means a great deal when developing CT in a new nurse.

Eventually a critical thinker can see the big picture and think outside the box, but no one can critically think without having the foundational knowledge (nursing school) AND the confidence in tasks. In the beginning of a nurse's career-when they are in orientation and then on the floor, they must first master the tasks before they will be confident enough to think outside the box. In Benner's model - the advanced beginner or the nurse that is in the first few months of practice has tunnel vision and only sees what she or he needs to do. They have a hard time prioritizing and the hardest skill for a new nurse to master is delegation. Building up their ability to become master technicians (all while asking the right questions) helps them to build their CT skills.

As we practice our profession, we expand and enrich our professional knowledge. For instance, if you are expert in symptoms and their management, you have more information in your brain to inform your already well practiced critical thinking.

Critical thinking skills should be developed over the lifetime of every human. We see evidence, everyday in our work of people who have poorly developed skills. These skills DO translate many many times into the nursing model. New grads who have more general life experience that demonstrate good critical thought development are more attractive to me as a manager than a new grad with little life experience.