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Advice for critical thinking


I lack critical thinking skills on the clinical floor during my rotation. I would like to know how a nurse thinks critically?

HouTx, BSN, MSN, EdD

Specializes in Critical Care, Education. Has 35 years experience.

That's a tough one. It's like asking a golfer whether they inhale or exhale on their backswing.... or becoming aware of one's tongue. Just thinking about it can interrupt the "normal" and make it clumsy or inaccurate. But here goes.

Rather than using the traditional term of "critical thinking", I prefer to call it "clinical reasoning" because it is a better representation of what I'm talking about & it infers a limitation to clinical practice... whereas CT applies to everything in life. Anywhooo, it's all about situational awareness or being able to place everything into a bigger picture.

Example: while taking a manual blood pressure, I'm checking the color, temperature & texture of the skin; thinking about the meds that the patient is on & how they affect hemodynamics; noting whether the pulsation is regular or not; etc. If there are abnormalities, I'm processing that information and figuring out what it may mean in terms of the patient. Is the systolic high because he's upset or scared? Was he exerting himself? Is his temp going up? Is circulating volume decreased? . . . it's a continual internal dialogue that is constantly taking in new information about the patient and making sense of it.

Here's another one (true story): new ICU nurse taking care of newly admitted AMI, so he was administering MSO4 for chest pain as per the physician's order. The nurse was so focused on relieving the pain that he completely failed to note the effect on respiratory effort & pulse ox. I (ICU Educator) heard an alarm and trotted in to see it I could help... patient was becoming noticeably ashen/cyanotic & the nurse was pushing more MSO4. Everything turned out OK, but when I asked the nurse he said he just 'lost track' of what else was happening because the patient was still complaining of chest pain and his ST seg was so elevated which seemed to be clear evidence of anginal pain. That nurse had lost situational awareness . . . unable to keep the whole picture in in mind. He was only processing information that was directly related to that one issue.

Clinical Reasoning (Critical Thinking) requires a continuous 'scan' and interpretation of available information - even stuff that you may think is not relevant - and analysis of that information in terms of what is (or could be) happening with your patient. I am not really convinced that it can be taught... we can only help people understand what it takes and the rest is up to them. It takes a lot of effort.

Agree with PP that this is something that can't be taught; it only comes with experience and it's the main difference between a novice and an experienced nurse. It's the ability to integrate small pieces of info into a bigger picture. As a nurse you are always assessing your pts and analyzing the assessments in the context of the pt's clinical picture. In order to analyze, you need to have a basic underdstaning of anatomy/physiology, disease processes, medications and the side effects, while keeping pt's medical history in mind. My advice is to research anything that you don't know about or not sure of, and always ask questions. It will come with time, practice, and effort. You'll feel like you "clicked" once you are able to think critically.