Critical Thinking Development

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Hi everyone,

I'm a relatively new nurse; I've been working for almost a year. My most recent performance review concludes that I am sorely deficient in the critical thinking area. This is obviously both incredibly discouraging and alarming. Is critical thinking in nursing something a person either has or doesn't? I have a BSN and yet I haven't come out qualified enough to do the job well. I know some of it will grow with experience, but I am below where I need to be right now. What can I do, if anything, to develop this skill? I need to address this ASAP!

Any help please!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

What are some examples that they felt you lack critical thinking skills? maybe we can help. How long have you been out of school?

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I am relatively a new grad too, but it did take me maybe a month or two to kind of feel that "comfort" in nursing work. Of course it wasn't 100% comfort, and I still went to seek advices from my charge nurse time to time, but most of times, I was on my own. On the other hand, I witnessed some other new grads who worked with me at the time, and they took a bit longer to get used to and catch on the pace. Granted, there is NO person who can walk into a job first day and know what to do and be proficient in critical thinking.

Many times, I see critical thinking as prioritization-reprioritization, because that's what happens at work as an RN. You walk in and have good, easy day assessing walkie-talkie and medicate them, then boom one goes a fib, other one has critical blood sugar, then other one deteriorates in blood pressure... then the RN critical thinking kicks in and you just get right onto getting orders from docs and carrying them out. I worked at pretty tough sink or swim unit, so that helped me learn quick, but I guarantee you critical nursing thinking never comes innately. It's all learned through experience, and never forget to reflect on those experiences. You will do fine!

PS: and by the way, having some cajones (sorry if this is bad word, I don't know) really helps, but also very important to ask and learn what experienced nurses will do in certain situations.

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Specializes in Hospital Education Coordinator.

I used to think you were born with it or not. Now I believe you can train yourself to address siutations to prioritize and re-frame your thinking. Besides the excellent sources listed above, do some research on emotional intelligence. If you can get hold of the magazine "Psychology Today, April 2013" issue there is a great article regarding this topic. I used it to create a seminar for charge nurses.

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Sometimes when going about my work, I ask my self "why". You should be able to explain why you are giving the meds, why certain tests were ordered, why the fluid bolus is a good idea or not.

On a slow day, I practice "what if" scenarios. I imagine what if the patient goes asystole, what exactly would be the first thing I would do? What if.. scenarios give the brain a thinking workout.

If you work long enough, you will work through plenty of scenarios in real life.

If you truly don't have critical thinking, nursing is strictly a checklist of chores to get through in order with no thought to the goals they are supposed to accomplish.

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Critical thinking can be learned. And will come easier with experience. Use your resources, as nursing should not be a solo sport. Sometimes when a nurse feels overwhelmed, it is difficult.

Really work on good assessments. Take more than a few notes on your "paper brain" at report (and if you don't have one, now is the time to create one). Take a few minutes and review your chart--your orders, the meds, test results.

When I was learning to critically think, I needed a "total picture" of the patients I was caring for. Snippets of information here and there doesn't work well going in. Why is the patient admitted, what is the goal, and how are we going to get there? What is preventing a successful goal outcome? Can it be fixed? Who needs me RIGHT NOW? Be mindful of changes in condition. Know what to do (rapid response. for instance) if there is a change.

Finally, when there is a performace review that has some negative (and we all get some negatives) there should be a plan in place for improvement. That is goal based and timelined. With follow up meetings to check progress.

Best of luck, and you will get there!!

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Specializes in ICU.

That advice to always ask "why" is great! I don't know if you have any free time at work, but if you do - really think about everything that's abnormal with your patient and ask yourself why those things are abnormal. Don't just report it to the doctor or pass it on to the next shift. If a patient's potassium has hit 5.2, for example, why is it high? Does the patient have good kidney function? Has he/she been running fluids with potassium that need to be turned off? Is the person getting tube feedings or TPN - does the formula need to be changed? If you start thinking through why each finding is what it is, and what can be done about it, the critical thinking kind of comes with the territory. Question everything, and figure out why it's happening. At least half of the time if you can figure out why something is happening, thinking through what to do next is much easier - not to mention, the physicians will like you a whole lot better if you take steps to fix a problem before calling them about it. For example - "Hi Dr. So and So, X's potassium was high, but he has only voided 200ml all night long and he has been running IVF with 20 mEq KCL for the past two days. I just stopped his IV fluids. What other actions would you like me to take at this time?"

Now, if you don't know why something is happening, and it's not some off the wall abnormal thing for the patient's condition, I suggest you go back to your med-surg book if you still have it and look up the diagnosis on your days off. I'm sure you will probably have another patient down the road with whatever the diagnosis is, and if you don't know what's normal for a certain patient population and what's not, you're not going to be able to critically think about what's going on with the patient.

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These are all great suggestions! Thank you all! As for an example I was given, here's one: I had a patient who started to have some oxygenation issues. I kept trying to get an accurate O2 read on the pt--I had no problem doing so at the start of the shift but now it was almost impossible and I couldn't keep it going so that I could keep continuous track of it. I enlisted the help of my charge nurse to get a reading. The patient was not in any overt distress at the time. At the shift went on, I noticed that she was behaving differently. Coordination wasn't good, the patient had hand tremors that were new..overall I didn't like the pt's look. I called the doctor a couple of times. The pt had gotten some Lasix in the ED but no output for me. I checked with ED and they didn't have anything out for the pt either, so I figured Lasix again might not be the answer. My charge nurse didn't seem too concerned, but looking back I should have called the doctor to come see the patient. I ended up putting in a catheter (I bladder scanned the patient and the patient was retaining in a big way) and got a lot out. Pt seemed a bit better after that but I still wasn't happy. I asked the charge if I should do an ABG and he said that probably wasn't needed yet. Anyway, we made it through the night and at the start of the next shift patient was transferred to the ICU.

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Remember, if the extremeties are cold, the O2 sensor will be inaccurate. Hand tremors could indicate the patient was cold. And the patient should be on I&O's if they are on lasix.

Always remember head to toe, and your ABC's. The patient is "not right in the HEAD", is having work of BREATHING, and has not PEED. (Head to Toe--and you can always add--is the mental status different, was the work of breathing always present, and is the patient always retaining urine.....so that you are in tune to changes)

So, always call the MD if you are concerned (or a RRT if the patient is in distress)

Sounds like you were on the right path, just need to remember to use your resources.

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Specializes in ICU.

You did recognize problems with the situation, which is good, but if I see a neuro change, I always do a really brief neuro assessment to see what that tells me. Even that quickie FAST deal for strokes would have given you information. All you'd need to do is ask the patient to hold up his arms, ask him to smile, and ask him to repeat a phrase like, "You can't teach an old dog new tricks." It could definitely have just been an oxygenation problem, but no one's going to get you for gathering extra data, and at least you can almost totally rule out a stroke as a cause of new-onset neuro changes. :) Also, if I'm having a problem getting a good pulse ox on a person and when I do get numbers, they are spotty - I'll just go ahead and throw extra oxygen on and see if my pulse ox starts reading better.

You quite clearly have good instincts if you did get a persistent feeling that something was wrong, so you're on the right track! It just takes time. I'm still figuring out all of this business myself.

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