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Discussion

Critical thinking development

I've been a nurse for about 9 months now and I had a situation a few weeks back that made me question how well my critical thinking skills are developing. My patient had a nephrostomy tube 2ish days postop that had been draining urine beautifully all night, when at 0630 (of course it would happen right before shift change!) they rolled over and felt a sharp pain at the insertion site. I went in to assess the patient and his neph tube was now draining frank red blood. Otherwise asymptomatic. My charge nurse was off the floor at the moment, but thankfully the day nurse (who I'd gotten report from the night before and was getting the patient back) was already there and clocked in.

I knew that I needed to call the doctor and report what had happened, but it seemed like my mind went blank of everything else. Really basic stuff that I would have forgotten if the day nurse had not done it while I was paging the physician, like getting a set of vitals so I could tell the physician that the patient's BP was stable and the fact that the patient was on a heparin drip so I could get orders to stop it (important stuff!).

I'm so very grateful to the day nurse who helped me, and as soon as he mentioned something (like that he was going to get vitals for me) I immediately agreed that he was right and remembered those interventions would be important. But I'm concerned about what would have happened if he had not been there and I forgot to tell the physician the patient was on a heparin drip. I got so focused on the immediate issue I completely blanked about all the related issues.

I suppose what I'm ultimately asking is how long did it take for you to develop your critical thinking skills? I understand that I'm still a fairly new nurse, but should I be farther developed in my critical thinking skills at this point? And if so, what can I do to further develop them? Thinking back to my first few months on the floor, I know that I have improved a lot in this area, but I'm just concerned that one of these days it won't be enough.

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    It will come with time. Just continue to ask questions when you are uncertain and get help as you did.

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    Developing critical thinking is a life-long process. I've been a nurse since Dec., 2004, and I *still* learn new things every day. They don't call it practicing medicine for no reason! It may help to think about what is going on with your patient like you are a detective looking for clues. What pieces of information would help the doctor (and you) figure out what's going on? Try to gather enough info to paint a good picture (as time allows) before you call.

    I work with a pretty senior group of nurses, and we problem solve together at the nurses' station on many a day. We're all human, and we all have room to improve. Don't be hard on yourself!!

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    I'm eight years in and ask for advice and second opinions all the time. My coworkers ask me things all the time, too.

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    It may help to think about what is going on with your patient like you are a detective looking for clues. What pieces of information would help the doctor (and you) figure out what's going on? Try to gather enough info to paint a good picture (as time allows) before you call.

    Excellent advice, Buckeye.

    You'll always want trending & recent vitals, and a list of meds. Make a list: what other things go into SBAR?

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    Critical thinking is the last skill to be developed. You'll get better... and some of the stuff you learn will be applicable to other situations, but there will always be new conditions and complications to learn... and new knowledge in nursing/medicine that will change our current paradigms of thought. Give yourself a break.

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    • Expert

    On the other end of the spectrum, I find myself not being able to connect dots as well as I did when I was younger.

    For example, when I worked as a scrub in surgery, I enjoyed the chess game of thinking several moves ahead and anticipating the surgeon's needs. Nowadays, I have to really concentrate hard and focus and think and consider in order to get from point A to point C.

    Thank God for great coworkers and the team approach, or I would have stumbled and fallen a few times!

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    Thank you all for your responses and encouragement. I am so very grateful for my team, who is nothing but supportive and I have learned so much from them! I just get a bit nervous because I work on a fairly high turnover floor and right now the most seasoned nurses on the floor during my shift only have 1-2 years more experience than I do, so pretty soon I'm going to be the one nurses are looking to for advice and to keep a calm head. But one step at a time, and I know that I'm way more competent now than I was when I started out, so I just need to keep learning all I can (especially from all the lovely allnurses people!)

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    When I was a new nurse I developed a cheat sheet I could use on a daily basis I copied 20 sheets on a monthly basis. On this cheat sheet were vitals, any labs, dx, name, you know the information you need when you give/get report. I would fill it out before I called the doctor. It take a min and I feel like I wouldn't forget anything. It was very similar to SBAR. This assisted me with centering my issue for the doctor. It only takes a min and I was always treated with respect from the doctors I encountered.

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    Now you know, whenever trouble arises, a set of vitals is needed.

    There will be many times when it won't help, but it rules out a bunch of stuff.

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    • Columnist

    Maybe it was more panic than critical thinking? I think you knew what to do but

    not in the right order.

    Your intent to notify the provider pushed everything else aside. Just step back and take a breath. Best wishes.

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    You said it was at the end of your shift . . . fatigue? I know that I'm much sharper at the beginning of my shift than at the end, when all I want to do is get home before I fall asleep!!

    That said, everyone has a brain fart every now and again. It happens. What is your critical thinking like for the other 11 hours of your shift?

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    • Author

    Sorry, I did not realize I had a few more responses to the post. After having some time to think and reflect, I do think there were a number of factors at play in that situation. Yes, critical thinking development was probably the main one, but like Nurse Beth said, I probably panicked a bit, and like RubyVee mentioned, it was the end of the shift and I was fatigued. Overall, I've decided to stop feeling frustrated about what I did wrong and choose to learn from the situation so I can do more right next time. They'll always be something I can improve on, but I did learn a lot from the situation, and the patient was not harmed by my actions, which is sometimes all I can hope for.

    Thank you all again for your responses and ideas!

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