Critical Thinking: How To Inspire It?

  1. Hi AllNurses.com Friends,

    Much is said and written about the importance of critical thinking and how it affects the quality of patient care.

    Everyone has an opinion:

    The National Patient Safety Foundation (NPSF) Discussion Forum:

    Jo Ann Klein, MS, RN's commentary on "Critical Thinking in Nursing": "What is critical thinking in nursing? Ask a dozen nurses, and you'll get a dozen different answers. Primarily, critical thinking is a method of problem solving requiring reflective thinking. It is built on an individual's ideals and value system, and is purposeful and goal-directed with the intention of making decisions."

    Academic medical center nursing director:
    We have a tool to evaluate critical thinking in our new hires.

    Competency training participant:
    It's just common sense - doesn't everyone do that?
    But . . . . in the last 12 months, two almost-identical tragic events occurred in the same ICU area . . . in both cases, 4-5 doctors and nurses made flawed assumptions (e.g., ok to ignore alarming equipment because it must be broken).

    Sure, everyone knows that theory and reality are worlds apart. Okay - but surely there's a solution? Or, at least a workaround?

    So, what do YOU think? I can use help! Thank you!
    Last edit by Team HPNI on Jun 7, '03
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  2. 41 Comments

  3. by   gwenith
    Okay - I seem to be the only fish biting here and it is a topic I want to debate but unfortunatel y time at the moment is against me. I will tag this discussion and "subscribe" to the thread so that I am notified by e-mail of replies and if you do the same I will come back and answer your questions after a good long think, read and ponderance.

    PS you will get more responses if the first part is a little less "academic". Most nurses on this board are everyday working nurses (me included) and we fall out of the pattern of academic thinking and speech. After a while it becomes almost "threatening" to have to deal with it again.

    Bring it down, open it up and if possible throw in a scenario or soem humour and people will respond.
  4. by   BBFRN
    I'm an everyday working nurse, and I understand the question. But, maybe there are other factors to declines in critical thinking patterns in clinical staff, such as lack of sleep, long working hours, staffing shortages, bigger patient loads,staff morale, etc. Are you sure that it's just a matter of "encouragement," or do these other factors correllate with one's ability to always be on their toes?
  5. by   Team HPNI
    Dear Gwenith and Igflamini,

    Thank both of you for being so responsive.

    Gwenith's comments are right on target - I understand and revised the message. Igflamini's ideas are also on target. Encouragement is not the major factor - morale problems caused by exponential increases in workload and expectations are hard to overcome.

    Part of my responsibilities include talking to nursing staff about "chain of command" as part of their competency training. In the classroom, I see eager, bright minds - willing and enthusiastic about independent thinking. Yet, in patient care situations, I see the often tragic results of lapses in critical thought.

    My goals in posting this message are:

    1. To better understand why these lapses occur
    2. To identify solutions
    3. To learn from others

    Thank you for your time and thoughts. Much appreciated!
  6. by   Team HPNI
    Well, to answer my own question and raise a few more questions . . .

    Today's NY Times (June 7, 2003) has an interesting article, "NASA's Failings Go Far Beyond Foam Hitting Shuttle, Panel Says."

    A few key phrases.

    "NASA's problems go far beyond falling foam, according to an early outline of the report by the independent panel investigating the accident that doomed the shuttle Columbia and its crew.

    The failings include an institutional culture that plays down problems, as well as constraints from Washington that may have reduced the ability to reach space safely.

    The outline portrays the fatal Columbia mission as the tip of an iceberg of problems that include communications breakdowns and an increasingly complacent attitude toward warning signs. Budget pressures and administrative shuffles add to the pressure on the National Aeronautics and Space Administration, the report suggests, and may have contributed to the troubles."

    Based on this article, I guess "institutional culture," "communication breakdowns," and "complacent attitude" are contributing factors.

    Hmmm.

    Thoughts?
  7. by   BBFRN
    Interesting. I can only speak from personal experience, but the things that I have used to keep my critical thinking skills honed are: continuing to further my education, taking accreditation courses at my hospital (and non-accreditation courses such as wound/ostomy care, etc.), and thinking about the MD orders I'm given, esp. if they're not the usual orders. I try to find why the orders were given, what the MD is possibly looking for. This is of course, if I have the time to do this. It keeps my interest peaked, at least. Plus, I don't work in an area that bores me. I think that one of the key elements of critical thinking is autonomy, right? Not a lot of working nurses feel very autonomous right now, unless it has to do with the prospects of losing our licenses- then we are all to ourselves. I think that there are so many factors to consider in this, that I wouldn't know where to begin! We have all displayed some amount of critical thinking skills, otherwise we wouldn't have passed the boards. Maybe some of us are too busy trying to keep our heads above water that we don't see the sharks swimming below?
  8. by   Team HPNI
    Thanks for speaking from personal experience. Mine is limited and I greatly appreciate your willingness to share.

    Taking courses to continue one's education, thinking about orders, exercising autonomy - these require time, energy, and dedication. But the rewards are great.

    "It keeps my interest peaked." I completely concur. Independent thinking, objectively evaluating the situation and determing the optimal course of action under given circumstances - these activities engage the intellect and imagination and enhance the individual's sense of purpose. Gives people a chance to contribute - to "make a difference."

    Warren Bennis once wrote that successful organizations are populated by people who think.

    People are an organization's most precious resource. Thinking people are priceless.

    So, perhaps leaders need to create a working environment where staff have enough time to exercise their critical thinking skills.

    Thank you for providing food for thought. I like to muse about these things (as I enjoy my Starbucks - in my case, a Vesuvious-hot Venti Misto!).
  9. by   BBFRN
    Originally posted by Team HPNI

    Taking courses to continue one's education, thinking about orders, exercising autonomy - these require time, energy, and dedication. But the rewards are great.

    "It keeps my interest peaked." I completely concur. Independent thinking, objectively evaluating the situation and determing the optimal course of action under given circumstances - these activities engage the intellect and imagination and enhance the individual's sense of purpose. Gives people a chance to contribute - to "make a difference."


    So, perhaps leaders need to create a working environment where staff have enough time to exercise their critical thinking skills.

    Thank you for providing food for thought. I like to muse about these things (as I enjoy my Starbucks - in my case, a Vesuvious-hot Venti Misto!).
    I like to muse about these things, too! It's great to find others that see this from a philosophical point of view. And I think you hit the nail on the head for me, at least- it does allow me to feel like a vital contributor. It makes me feel good to see something (no matter how subtle) going on with a patient, and think, "Hmmm...I wonder if this could mean ________?" And then to further investigate it, maybe get a 2nd opinion from another experienced nurse, and take it to the MD. How many things we can nip in the bud by doing so is amazing to me. I think that yes, most Nurse Managers don't consider heavy patient loads to be a factor in whether we are using our critical thinking skills in full effect at times. Some seem to think that CEUs are all we need to keep us on our toes. I am fortunate enough not to have a NM like this, and she stands behind us in these situations, but she does have a very hard time keeping us adequately staffed, no matter how hard she tries at times. The problem on our floor goes beyond her from what I can tell. Sometimes, it's up to us to spend a little of our off time educating ourselves, if only to keep ourselves interested in what we're doing.
  10. by   Team HPNI
    Lead By Example

    I think that yes, most Nurse Managers don't consider heavy patient loads to be a factor in whether we are using our critical thinking skills in full effect at times. Some seem to think that CEUs are all we need to keep us on our toes.
    Thank you for zeroing in a problem - identifying problems is the first step toward resolution. The consequences of time constraints are underestimated; the benefits of CEUs are often overestimated (in my opinion).

    Sometimes, it's up to us to spend a little of our off time educating ourselves, if only to keep ourselves interested in what we're doing.
    I agree 100%! Education is an investment in ourselves.

    Your organization is fortunate to have you on their team. I once read that "example is not the best way to influence others. It is the only way. Lead by example - you do!

    Well, now it's time for me to go home, clean the floors, do the laundry, and other home-improvement stuff. The good thing about such banalities? Tangible results. You can really see the difference when the floors are clean!

    Happy Saturday!
  11. by   BBFRN
    Thanks for a though-provoking conversation!
  12. by   Riseupandnurse
    In my masters thesis, I performed research on a beginning nursing student in an attempt to discern the nature of beginning nursing thought, with the purpose being a possible revelation about nursing critical thought. I learned many interesting things, and I discovered during my literature review that much of what I saw in my research had been observed and predicted by others.

    The biggest threat and impediment to nursing thought and nursing critical thought appears to be task orientation. Task orientation is simply "putting out fires" under the pressure of getting the chores done. There is no critical thought possible in a nursing student who is motivated by task orientation. Patricia Benner has commented on this as well, that when nurses are motivated by the accomplishment of tasks, little critical thought takes place. But task orientation is encouraged by health care staffing and by our national system of paying, in which nursing care is treated as just another fixed cost, like housekeeping, that ought to be kept as low as possible. It doesn't matter how educated a nurse might be, or sometimes even how much experience that nurse might accumulate, if the nurse has no time to reflect on the patient, because critical thought (which seems to be discipline-specific) absolutely requires reflection.

    I have just returned from a typical 14 hour shift, and am eating my first meal of the day, even though it's after 10:00 p.m.. Was I able to give critical thought to my nursing today? To some extent I was, but only because I gave up meals and breaks and struggled to fit the essence of nursing into my endless rounds of medications and tasks. Nursing will never reach anything near its real potential until the health care delivery system changes. And it will never change unless nursing itself makes it change.
  13. by   Team HPNI
    14 hour-day? First meal after 10 PM?

    It's amazing that anyone has the physical stamina to even attempt "to fit the essence of nursing into my endless rounds of medications and tasks."

    Your insights on "task orientation" are logical. I have heard nurses describe the challenges of trying to add notes to the patient's medical record. Imagine an ICU scenario:

    Alarms, codes, constant monitoring required. The nurse starts a sentence, interrupted by an alarming ventilator. After responding to the crisis, she returns to documentation, only to discover that the chart has been moved to another location. After tracking it down, she completes the sentence - but before she can finish the note, another crisis erupts. Again, after responding to the code, she must hunt down the chart before completing the note.

    "Tsunami effect" is my vision of the "putting out fires" crisis-mode inflicted on health care workers. Too much happening, too fast, with too few staff to respond. Although my dissertation was based on the idea that work can be fun when it's purposeful and contributes to a meaningful goal, too much work, with too few staff, is NOT fun. It's closer to Hell.

    "Task orientation" is a good explanation for why critical thinking is not always the top priority. Thank you for sharing your insights.

    On your conclusion:

    Nursing will never reach anything near its real potential until the health care delivery system changes. And it will never change unless nursing itself makes it change.
    In your opinion, what might be the best way(s) for nursing to promote health care delivery system changes? Organizations like ANA?

    Thank you for taking the time. I hope you get a chance to have some Starbucks (or whatever you might prefer).
  14. by   CRNA teacher
    Complex topic, with lots of issues.

    I like the reference to Warren Bennis-isn't he the business leadership expert? I am glad to see other nurse familiar with his work. I like his idea of the leader as facilitator, and not neccessarily the micromanager.

    I also thought of Patricia Benner's work. If I remember, she documented the evolution of ICU nurses from novice to expert, and the role of "grey gorillas" as mentors to novices. I think it underscores, that while you cannot eliminate the "book work" and study aspect of learning good nursing concepts, much of what makes nurses experts is experience. And that experience is not taught in the traditional way, but is more intuitive.

    So, while the recommendation to continue eduction is essential to the growth process, focusing on pure academic/classroom education may not be enough.

    In the original example, two different teams of care providers failed (or nearly failed) to believe alarms and act accordingly. I find it difficult to believe that none of those involved had sufficient KNOWLEDGE. The broken link in the chain involved the processing of information and the decision to act.

    I am not an expert on simulators in education, but is a hot topic at my school right now. We believe we have the institutional support to start a simulator program, and we have been exploring this relatively new technology. It is incredibly exciting. What was not too long ago only possible in the large academic centers, is beginning to become more available to other settings.

    I believe simulators relate to this topic. The idea for simulation began with the aviation industry, as a way to teach crisis management. It is doing the same thing for health care. The value of simulation is it fills the gap between "book knowledge" and putting that knowledge into action in the "real world".

    I know simulators are not widely available yet, but that is sure to change as technology marches forward. Anyone have experience with their role in education, and their influence on the development of critical thinking skills?

    CRNA teacher

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