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

Nurses Professionalism

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I was told during my brief stint working med surg that you either have critical thinking or you don't. Thoughts?

Grntea, I believe in your type of thinking. It's not a matter of agreeing or disagreeing but what "critical thinking" really is. My whole purpose in posting this question was to point out how assenine it is to make a statement as such. This so called "all or nothing" mentality was verbalized to me several times during my experience on this particular med surg floor. The nurse manager stated she thought I was too task oriented, slow and overall was concerned with my performance and said "I think you could put a patient at risk". I had a lukewarm relationship with one preceptor in the beginning of my orientation for nights then I was switched around between 2 preceptors for the day shift because my first one stated "I don't think I could train you." That made my anxiety skyrocket. I never, ever caused harm to a patient but I was constantly asking questions. I had minimal experience with IV therapy prior to starting on med surg, that made me uncomfortable. I admit, I was very focused on tasks and just learning to get through my shift. I had never worked an acute unit an was anxious going in and felt like I lacked general support and understanding. At the time of my hire on this floor I was an RN for 9 months. I took that PBDS test and got an "unacceptable" twice. Based on that, my nurse manager decided to say I "lack critical thinking". I looked up my diagnoses, asked questions and overall tried my best to be interested in any and all learning opportunities.

Anyway, I guess in a round about way I'm saying that I feel that being a critical thinker is created through the nursing practice. Not some special gift. All nurses must work to do this which is why it's called nursing "practice".

LTCnurse11, on the subject of critical thinking, I was wondering, given your post above, if perhaps some of the difficulties you are experiencing are due to not using the nursing process (the systematic approach to identifying a patient's problems and to implementing nursing actions to solve those problems) as effectively as you could: i.e. assessment (subjective and objective); diagnosis; planning; implementation, and evaluation. Perhaps considering how you are using the nursing process in your practice would be helpful - of course only you can determine if my suggestion is applicable to your situation. If you do determine that it would be helpful for you to improve in this area and need resources, there are books on using the nursing process in clinical practice.

I hope this is helpful, and I wish you the best.

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LTCnurse11, on the subject of critical thinking, I was wondering, given your post above, if perhaps some of the difficulties you are experiencing are due to not using the nursing process (the systematic approach to identifying a patient's problems and to implementing nursing actions to solve those problems) as effectively as you could: i.e. assessment (subjective and objective); diagnosis; planning; implementation, and evaluation. Perhaps considering how you are using the nursing process in your practice would be helpful - of course only you can determine if my suggestion is applicable to your situation. If you do determine that it would be helpful for you to improve in this area and need resources, there are books on using the nursing process in clinical practice.

I hope this is helpful, and I wish you the best.

As far as using the nursing process, I am familiar how to use this in my practice. My problem did not lie with just that area but the orientation, lack of experience and general failure in putting the pieces together. I was feeling disconnect during my experience there. Not sure if only I was not getting it or a combination of factors. Acute care was very new, and I know now what it takes to make it sink or swim.

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From my old copy of " Asking the Right Questions - A Guide To Critical Thinking""

" Reading critically, that is, reacting to what you read through systematic evaluation - requires a special set of skills. These skills basically consist of the ability to ask and answer a series of critical questions."

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Specializes in Pediatrics.
It seems to me that many of these posters are equating "critical thinking" with "experiential knowledge." This is not accurate. There are lots of people who have tons of experience who couldn't reason their ways out of damp paper bags. There are new nurses with little knowledge whose critical thinking is already in place-- and part of the evidence for that is that they mindfully seek out more parts to the puzzle when they can't see the solution clearly right off the bat.

This is not to say that these newbies were born with critical thinking skill, although those who were raised in an environment that rewarded and reinforced independent thought, curiosity, and problem-solving probably bring more to the table than those who weren't. Critical thinking can-- must-- be learned.

Agreed. I see this in education. There are three types of students: the haves, the have nots, and the potentials. I see very bright students who can memorize the books, notes, signs and symptoms, with a wonderful bedside manner. But they have no ability to critically think, problem solve, or "connect the dots". When a student takes the same class twice, with the same content, and very similar test questions (same concepts, different questions) and cannot pass, this should be a red flag.

That is not to say that CT cannot be developed. If nursing was all about critical thinking, some people should have no need for nursing school. I believe that common sense is a key player (and agree that it's not so 'common'). I believe environment has a LOT to do with it. I believe the kind needs to be challenged. I look at kids today, and I worry about the percentage of critical thinkers that are up and coming. Parents today coddle their kids, and don't encourage them to think. They do everything for their kids, to protect them and make their lives easier, when in reality they are not.

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Years ago, more years than one cares to admit (*LOL*) my freshman high school English teacher (Mr. Brown) opened our first day with a lesson on critical thinking.

Using the then popular advert line " 4 out of 5 dentists surveyed recommded sugarless gum for their patients who chew gum", the class was asked a series of questions.

Did the statement mean that a majority of dentists recommend chewing sugarless gum?

Did the statement mean dentists recommend chewing any sort of gum?

And so it went.

The upshot of this lession and what we learned more of that semester was how to read and think critically. We would have to read articles in the New York Times and write about their content as homework and or exams.

What one learned then and it has carried me through college and my life so far is that it is all about asking the right sort of questions in response to what one is told/reads. In one form or another we all use critical thinking in our lives. Everything from voting to deciding how to care for/raise our children demand some sort of thought process to weed through the noise and get down to the nitty gritty.

For some seeing the forest for the trees come easily, others not so much but they will learn. However there is a group of persons that simply cannot process data and arrive at a logical conclusion despite having reams of reference materials. Like Windows OS having a bad day they simply sit and "hang" or worse freeze and shut down.

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Specializes in cardiac, ICU, education.

Oh, a question for the ages. OP - As for your manager's statement; there are very few nurses who cannot critically think, but it is our responsibility as educators, preceptors, and managers to promote critical thinking. There is critical thinking which has many definitions but basically it is purposeful, results-oriented thinking within the context of a situation. Then there is clinical judgment which is an interpretation or conclusion about a patient’s needs, concerns, or health problems, and/or decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient’s response. Lastly there is clinical decision making which is the selection of interventions and actions that move clients from a presenting state to a specified or desired outcome state” (Pesut & Herman, 1999). Or in other words it is drawing valid conclusions and then acting appropriately based on those conditions à e.g. how to avoid failure-to-rescue.

You have to be able to think critically before you can develop clinical judgment and possess the ability to make correct clinical decisions.

Believe it or not, it is our responsibility to help new nurses in their first year to develop these skills as they can only be mastered in a clinical setting. We need to give them time to think, creative a positive learning environment, and promote a positive culture. We also need to provide “What if” scenarios and turn errors into learning opportunities, provide them with different solutions or options to a problem, and support new preceptee’s decisions – congratulate good decisions. If we have done all these things, but our new nurse is unable to think for themselves, then we can say that they are not critical thinkers. The problem is, many of us were not taught how to promote critical thinking. The idea of watch one, do one, teach one is archaic and still repeated to often.

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I would just like to say that to learn critical thinking, one must have the tools they need to do their job. This entails the clinical educator to be present when needed and lateral support from management and preceptor. IMHO, I felt I was exposed to a toxic environment from the start. The clinical educator and preceptor were only communicating on the wavelength of knowing my schedule and NOT taking time to assess my needs. I was uncomfortable with the Pyxis and the 3 different IV pumps they had. My weekly meetings were only my preceptor and manager and usually the clinical educator is supposed to be present. The clinical educator didn't even show up until my 7th week of orientation!

I'm willing to accept that I did not ask the right questions and I can confidently say my lesson has been learned. To move forward takes tremendous self reflection and changing of old, learned habits. I made a habit of documenting my progress and researching complicated cases. I'm not afraid to ask for help to place the patient first and strive for a positive outcome.

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Specializes in cardiac, ICU, education.
I would just like to say that to learn critical thinking, one must have the tools they need to do their job.

Absolutely. I would say you are lucky that you have a clinical educator to assist you through your orientation because there are nurses our there who do not have clinical educators at all (smaller hospitals) but it sounds as if yours did not help you at all.

You really shouldn't be held totally responsible for not asking the right questions either. You don't know what you don't know. As preceptors, we should be doing a lot of question and answer sessions with our preceptees. "What if" scenarios, What went well, what didn't? What would you do better next time? What has been your experience with this type of patient? What do you know about disease x? How can I help you learn? Help me to understand why you chose those interventions?

I could go on and on with critical thinking questions that preceptors should be asking their preceptees to get a better understanding of their thinking and to help them to solve problems with them and not for them. Show them CURE steps or have them watch me do a procedure or assessment and ask them purposeful questions about it when we are done. Not merely saying - do you understand - as that gives you minimal feedback into their thinking.

OP: I am so glad you did not give up, but rather see this as a learning opportunity for yourself on how to properly precept in the future.

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Interestingly, the term critical thinking, is open to numerous interpretations. Some people think other people aren't thinking critically when they are, they just aren't willing to look at other issues at play, and vice versa. It's a term that has been tossed around so much, it's competely open for interpretation.

And while EBP is good in many ways, it too has it's limitations. This is why I say I would be thrilled just to have people using logical processing, apart from emotional influences, more than anything else. I could give a zillion example, and I think it would lead to a thread war, so, I will hold off on some great examples.

Also, some people get nervous, and even though they can think logically and intelligently, they haven't had the opportunity and training to think in drilled situations. This is part of why soldiers are drilled over and over again; so they do certain thinking automatically, rather than adding emotion or other issues into the process. This can be good or bad; but when it comes to protecting yourself or your buddies, some things require immediate action without a lot of diliberation. But people can practice thinking things through in stressful situations if they have the right support and guidance. Often, they don't have the right support and guidance, only people that are too quick to judge them as buffoons or clueless or whatever. And yes, then there are those people that are given a couple a dozen chances, and they still can't get important things right. For most nurses, IMHO, it has to do with their level of confidence and the people that are coaching, teaching, precepting, and supporting them, or not. And I am not for babying students or new grads either. I just don't see the need to add to their already incredible levels of new nurse stress. Experienced nurses often forget what being new feels like. But there is a time for trained responses, and a time to think and deliberate logically, and there is also a time to look at things from a totally different perspective.

Finally, there are many different types of thinking for various situations. Some people are stronger in certain areas that others. This is one reason why teamwork can be a beautiful thing. Sadly, the lack of it can be an utter nightmare.

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Specializes in Trauma.

Could critical thinking just be a nursey way of saying cause and effect? Xxxx causes yyyy, xxxx will effect yyyy this way.

Just a thought. I like to keep things simple and familiar.

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Specializes in Medical Oncology, Alzheimer/dementia.

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?

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Interestingly, the term critical thinking, is open to numerous interpretations. Some people think other people aren't thinking critically when they are, they just aren't willing to look at other issues at play, and vice versa. It's a term that has been tossed around so much, it's competely open for interpretation.

There is so much truth to this situation. A lot of my orientation process was the issue of nerves and anxiety having been placed in a completely new environment. I had been having alot of anxiety to begin with. I felt the nurse manager was very interesting with her approach to my orientation plan and her initial expectations right from the start. In a phone conversation I had with her prior to starting my job, we discussed the PBDS testing scenarios and how it worked for employment. I voiced my concerns with the test considering my limited acute care experience. She stated "you don't need to worry because it just shows us where you're at for us to guide your orientation." She then stated "but I really expect you to do well on it." A few weeks later during a face to face conversation with her one on one after the first week of orientation, the manager stated "I did so well on my PBDS scenario the first time I didn't even need a full orientation. I wish I would have had more. But I really, really want you to do well".

With that comment, I took that to mean I had been expected to perform at a higher level of skill than an ordinary new grad with limited experience, so that started rising anxiety.

Also, some people get nervous, and even though they can think logically and intelligently, they haven't had the opportunity and training to think in drilled situations.

But people can practice thinking things through in stressful situations if they have the right support and guidance. Often, they don't have the right support and guidance, only people that are too quick to judge them as buffoons or clueless or whatever.

So here is an example of this. So my first 6 weeks on orientation I was placed on nights. This was to allow me to get used to the floor and get familiar with the charting. I was placed with a preceptor that was effective but the type to not give you warm and fuzzies. Mind you, I do not usually go to work and expect to make friends with everyone but this preceptor was something else. Well what a sight, this adult woman who told me flat out that she didn't like to orientate people, was playing on Facebook the first night I started. It was as though that was expected. So through my orientation, there were several things I had questions about and whenever I asked her I got the answer, but the problem was that when I did something wrong, I discovered that the nurse manager was told before me. For example we had 3 different types of IV pumps and prior to starting in the floor I wasn't orientated to a single one; therefore I probably spent the first 4 weeks of my orientation just understanding how they all operated which was a HUGE deal considering we almost always gave IVPB meds. I never gave many IV meds working in LTC so it was scary and felt dangerous. Same with IVP meds and PCAs. No clue how to use those.

So during our weekly meetings with the manager and preceptor, they discussed openly in front of me their "concerns about my med administration, especially IV meds". I was very clear that I wanted to feel extra comfortable especially with IV meds and that they really scared me. I then made a recommendation about not feeling my progress was being discussed in a constructive way and asked about getting more positive feedback during my learning/orientation. The manager stated "I'm sorry but I'm not an enabler" I told this to my preceptor and she stated "nor do I give compliments". They both then told me that I kept "looking for a pat on the back." I couldn't believe it.

I was feeling very insecure and anxious which was increased further with that. For all I knew if I was doing something really, really wrong I at least deserved to find out about it immediately and have intervention. But no, these issues just steadily continued to escalate. Thank goodness I got out before there was the chance for patient harm.

For most nurses, IMHO, it has to do with their level of confidence and the people that are coaching, teaching, precepting, and supporting them, or not. And I am not for babying students or new grads either. I just don't see the need to add to their already incredible levels of new nurse stress. Experienced nurses often forget what being new feels like. But there is a time for trained responses, and a time to think and deliberate logically, and there is also a time to look at things from a totally different perspective.

Finally, there are many different types of thinking for various situations. Some people are stronger in certain areas that others. This is one reason why teamwork can be a beautiful thing. Sadly, the lack of it can be an utter nightmare.

I critically think everyday and I do well with it. I just need to hear if others have been told "they got it or they don't". To me that's over simplified thinking.

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