Critical Thinking: How To Inspire It?

wishingmary · Jun 17, 2003

What I like instructors to do when encouraging critical thinking is asking thought provoking questions that I can take home and write about. For me to critically think about a topic I have not yet explored, I need time, a luxury but still a need. When critical thought has to deal with how I think, believe or feel, sometimes its profoundness is in the question that doesn't necessarily have an answer. Still it is fun to go through the problem because it is in the quest I can appreciate its' importance and its' profoundness.

This has truly been a thought provoking topic, I've saved all the threads into a file.

altomga, ADN, BSN, MSN, DNP, RN, APRN · Jun 17, 2003

This is a topic that has no real single answer to it. I watch many nurses that don't take needed "critical thinking" skills serious. They figure they can just pass meds, chart, and leave crap to the next shift!! This is a lack of morale and interest in your job.

EDUCATION is a big factor to keeping up on these skills. The pt's chart is always a wonderful place to learn. You see the problems, what the doc's are doing, and what has went on with the pt. I search the internet a lot to review diagnosis, procedures, and read this forum which will TEACH a tremendous amount to any nurse.

I am a permanent charge nurse and I take it upon myself to check on the new nurses, review their charting, the pt's charts to see orders, progress notes, etc. It is not to check up on their work persay, but to see "what they (the nurse) is thinking" I ask them questions, review diagnosis, rhythm strips, give them scenario's, etc.

Critical thinking is not always having the answer, but being able to intelligently think through a situation, and know where to go to to find the answer. Critical thinking skills aren't there when a nurse graduates, it comes with time. I remind the new grads of this all the time when they get discouraged. The "fires" should be put out to avoid pt complications, and the nurses need to know how to go about doing that.

We have multiple classes and self instructional modules at work. I am also the unit educator and am always posting educational bulletin boards, doing inservices, etc. to help increase staff knowledge.

One factor that needs to be looked at is that some nurses just don't care and are just there to get a paycheck. Again morale!

Staffing shortages affect this issue somewhat, but if you care about your work and pt you will make sure your critical thinking skills are primed and ready and you will know your resources to go to! The nurse must be self-invested into gaining knowledge and furthering their education. Not meaning go back to college, but keep up with new medical trends, procedures, etc.

EDUCATION, ASK THOUGHT PROVOKING QUESTIONS TO FELLOW NURSES, DISCUSS PAST PATIENT SITUATIONS TOGETHER, GIVE ENCOURAGEMENT TO ONE ANOTHER, DON'T MAKE EXCUSES FOR POOR PATIENT CARE!

Team HPNI · Jun 18, 2003

Thank you for analyzing the issues and offering such clear guidelines.

Critical thinking is not always having the answer, but being able to intelligently think through a situation, and know where to go to find the answer. Critical thinking skills aren't there when a nurse graduates, it comes with time.

I once read a memorable phrase: "Next to the possession of knowledge itself is the ability to turn, at will, to where knowledge is to be found." "Knowing where to go to find the answer" is so important.

I appreciate and agree with your conclusion:

EDUCATION, ASK THOUGHT PROVOKING QUESTIONS TO FELLOW NURSES, DISCUSS PAST PATIENT SITUATIONS TOGETHER, GIVE ENCOURAGEMENT TO ONE ANOTHER, DON'T MAKE EXCUSES FOR POOR PATIENT CARE!

And, in my opinion, all of this requires initiative. The desire to look beyond the obvious and "quest" (to use Wishingmary's wonderful term) for answers.

Stirring thoughts - thank you.

wishingmary · Jun 18, 2003

Altomga, I can tell you are a real jewel. I've been on floors where I've asked questions but got the brush off or a defensive reply. I am not sure if it was simply they didn't know and didn't want to admit it or that I was somehow questioning their care. Anyway, I got a transfer to the MICU and ask all sorts of questions and now I'm studying my critical care text for my last semester next fall so their answers can really sink in. The difference between the two floors besides the kind of knowledge is the openness to ask. The nurses here aren't afraid to say, "I don't know". Then they tell me the doctors they go to as resource persons. I love ICU nursing for that. Pride isn't an issue. One of my favorite leaders into a question is "May I ask a really dumb question? Those are usually the best. I hope I never leave that student mentality of trying to put two and two together with a curiosity that won't let it go. It was that mentality that drew me to this thread. A year and a half ago, the stages of nursing thought was part of our required reading and this thread made me go back and review it. This summer I've taken some classes to get a clue like ACLS and you know I passed. I didn't take it to pass just to get a clue but I studied hard and I still look over the stuff from time to time on my PDA. I've taken other classes at the hospital I work but their education department is rather small compared to some others in town. You are doing a great service to those who do attend. I'd like to get into education simply because I'd like the freedom of saying, Oh wow, this is interesting, listen to this..... and as a mentor to nursing students behind me, the best education comes from teaching.

Team HPNI · Jun 18, 2003

It takes courage to say "I don't know." Yet, it reflects wisdom.

The difference between the two floors besides the kind of knowledge is the openness to ask. The nurses here aren't afraid to say, "I don't know". Then they tell me the doctors they go to as resource persons. I love ICU nursing for that. Pride isn't an issue.

So . . . here's a dumb question . . . when you say "I love ICU nursing...Pride isn't an issue" - does this characterize ICUs everywhere? Or, does it depend upon the individual organization?

Thank you!

gwenith, BSN, RN · Jun 23, 2003

Originally posted by Team HPNI
It takes courage to say "I don't know." Yet, it reflects wisdom.

So . . . here's a dumb question . . . when you say "I love ICU nursing...Pride isn't an issue" - does this characterize ICUs everywhere? Or, does it depend upon the individual organization?

Thank you!

It very much depends on the institiution. One hospital with a large ICU where I worked recently viewed me as a "dangerous intellectual" because I read New Scientist!!! They were very closed minded and task orientated and the culture actively discouraged inquiry - as you can tell I voted with my feet but to give myself some credidt I did TRY to take the issues up with management only to be told that "A policy does not have to be written down to be a policy". This was said by an Assistant Director of Nursing. The "hidden curriculum", the "quiet culture", the attitude and mores of the hospital itself are pivotal in either encouraging or discouraging independant thought and critical thought.

An example from that hospital - Eye care was done strictly second hourly on all patients regardless of whethter the patient required it or not. To question this was to be branded a "lazy nurse" and not to be trusted. The eye care involved eye drops second hourly This despite that fact that that intitution had in the previous year finalised a research project proving that second hourly eye drops were less effective than using cling film to keep the paitents eyes shut.

Some of the reason for this culture was the high intake of new graduates directly into ICU who did not set foot outside of the unit and within a couple of years were given senior postitions. In other words there was a large group who did not progress beyond teh first stages of Benners taxonomy.

By contrast my current hospital uses evidence based practice and we know we are not "perfect" but we are willing to work toward improvement. Individual assessment and evaluation is valued not decried as "who do you think you are?"

I will return to my original assertion that critical thinking is not the only answer. There are methods and patterns of thought that are almost inherent within the human pyche and which influence how and why you think.

an example and a good party trick do the following sum (don't use a calculator):-

Start with 1000 now add 40 now add 1000 now add 30 now add 1000 now add 20 now add 1000 now add 10

Most people get 5000 as an answer but check it with a calculator -that is not the correct answer.

The brains propensity to indulge in tricks like these explains in part why drug calculation errors can occur.

Alarms that sound repeatedly will be ignored. It is the ancient story of the "boy who cried wolf" and has little to do with critical thought and a lot to do with common human reaction. When I teach new staff about how to set alarms i tell them they should be set close enough to warn but not so close that they ring repeatedly and cause you to ignore them.

The answers you have recieved on critical thinking have been wonderful and stimulating to read as have your posts. ( and yes I am familiar with Benner - a fellow Aussie!!) However may I add another thought to this mix.

Concept mapping. It concerns me that we, as a profession are not utilising the best concept maps for assessment and without the correct maps our basic first step is likely to be a false one.

Too many texts and articles on patient assessment concentrate on assessment of the normal patient and ignore or lightly address assessment of abnormality. Teh reasoning often given is that "If you recognise the normal you can recognise the abnormal" which in HMO is wrong. Recognising the normal only teaches to spot deviations from the normal it does not help the nurse to recognise the patterns of abnormality and pathways of deterioration likely to be seen in the acutely ill patient.

We have focussed on data collection often as an end in itself instead of looking at data that has meaning and is pertinent to the problem at hand. An example:- many ICU units in and around where I live do a set of "vascular observations" as part of patient assessment at the start of every shift. Now, it is unlikely that a 19 year old head injury patient with no inotropes running will develop vascular complications involving reduction of pedal pulses 1 week after admission to a unit. These same ICU's do not encourage assessment of the skin of the patients heels at the start of every shift and heel pressure areas are FAR more likely to occur than reduction of a pedal pulse. As I said are we collecting data for the sake of collecting data or should we utilise our precious time in looking for pertinent and likely problems. A very wise friend once told me "When you hear hoof beats think of horses not Zebras" Okay once in a blue moon it just might be a group of zebras escaped from a zoo but isn't it more likely to be a group of horses??

Again I thank you for your stimulating and thought provoking posts

Team HPNI · Jun 24, 2003

So many good thoughts. Thank you.

I totally agree with that we currently tend to view "data collection as an end in itself."

We have focussed on data collection often as an end in itself instead of looking at data that has meaning[emphasis added] and is pertinent to the problem at hand. An example:- many ICU units in and around where I live do a set of "vascular observations" as part of patient assessment at the start of every shift. Now, it is unlikely that a 19 year old head injury patient with no inotropes running will develop vascular complications involving reduction of pedal pulses 1 week after admission to a unit. These same ICU's do not encourage assessment of the skin of the patients heels at the start of every shift and heel pressure areas are FAR more likely to occur than reduction of a pedal pulse. As I said are we collecting data for the sake of collecting data or should we utilise our precious time in looking for pertinent and likely problems.[emphasis added]

Yes, computer programs can collect, compile, and graphically present data with ease and sophistication. But, data collection is meaningless in and of itself. The key to success lies in analysis and interpretation. To learn, we must first understand.

Donald Berwick says it well, in "Patient Safety Lessons from a Novice":

Lesson 3
I thought: Reporting is necessary to track problems and progress.
I learned: Stories are necessary to gain knowledge.
Reporting for measurement contains almost no information. Reporting that loses the 'story' is mostly a waste. We need to harvest the knowledge. We need firesides, not spreadsheets.[emphasis added] The question of "How many?" isn't powerful. The question should be "What happened?'

In my opinion, too much data collection becomes counterproductive. Information overload often leads to paralysis. Better an eclectic approach - limit the scope of data collection and intensify the analysis of what it all means.

Just my opinion, of course.

coastin · Jul 1, 2003

Originally posted by janhetherington
. 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.

.

There's that elusive time factor again...You're right on! Critical thinking must also include the time to do a quick chart review so that you can see the whole picture. If a nurse is overloaded, the focus becomes narrowed as he/she is forced to play "beat-the-clock".

Team HPNI · Jul 3, 2003

Dear Coastin,

Thank you for zeroing in on the importance of time. Staffing shortages and exponentially increasing regulatory/compliance-related procedures are significant challenges, as the time available for thoughtful patient care keeps diminishing.

"Work smarter" is easy to say but takes ingenuity and determination to accomplish.

I like your quote: "Never attribute malice to what adequately can be explained by stupidity."

Thank you, again, for sharing your insights.

healingtouchRN · Jul 14, 2003

amazing one would think pt load effects critical thinking. I have had 120+ hours of cont. ed this year alone, but after 2 deaths in two hours & > 50 hour work week, I was numb & hoping one more person would not code! Lots of things effect critical thinking, which is why I would not want a tired resident (or any other doctor) working on me. As a charge nurse I recognize when skills are hedging on "not happening" so I will jump & make sure my staff is making good decisions. Incidentally, one of nurses said during this code the other nite, "cycle the blood pressure-let's see if there is one?" I explained to her that one has NO B/P with Asystole. She says "oh"...... Just ongoing checks & balances.... :eek:

Win98 · Sep 7, 2003

I hope I'm not too late to get into this fascinating thread. I haven't visited the site for awhile, but now I am teaching clinical to 3rd year Diploma students, and after 2 weeks (2 days a week), I have discovered that the most important thing I have to "teach" these people is how to think. Which is what drew me to this thread. Fascinating reading - lots of great ideas, and loads of comments that match my experiences and my thoughts.

I have worked in ICU for over 20 years, and recently achieved a Bach degree. I am teaching in Med/Surg and I am facing a bit of a learning curve regarding what goes on in the general wards.

There are so many comments in this thread that I have enjoyed and benefited from. There are two that really hit home, and I would like to comment on.

The first is:

"Some of the reason for this culture was the high intake of new graduates directly into ICU who did not set foot outside of the unit and within a couple of years were given senior postitions. In other words there was a large group who did not progress beyond teh first stages of Benners taxonomy"

The ICU in which I work is a perfect example of this situation. Many nurses have been there for close to (or even more than) 20 years. They have done no continuing education, but they consider themselves experts, but as the above quote suggests, they have not progressed much past Benner's first stage, and critical thinking is not a concept that has ever occured to them. I think I was born curious, and critical thinking has been part of my daily life forever, so I find it very discouraging to work with people who are so task oriented, and believe that the best nurse is the one who is able to end the shift with the patient neat and tidy, and gives you a report beginning with "You will have a good night, there's nothing for you to do"

Another comment that struck home is:

" As I said are we collecting data for the sake of collecting data or should we utilise our precious time in looking for pertinent and likely problems".

An example of this that I see often is fluid balance charts on patients whose intake consists of on mulitple infusions, CRRT, and enteric feeding, and whose output consists of CRRT, urine, and chest tube drainage. The nurse is scrambling at the end of the shift and comes up with a balance something like +3273.5 ml. Give me a break!!!! How accurate is that, even if the math is correct, which it often isn't. But just because the insulin or heparin is infusing in decimals, these numbers are reflected in the fluid balance. Yes, it's important to note on the medication record that the insulin is infusing at 3.5 Units per hour, or the Heparin at 950 Units per hour. But, these same nurses can't answer your questions about the patients past history, or how long has he been on the amiodarone, or what is the distance marking on his PA catheter, just as examples. The last of those is one of my pet peeves, as I once when I was in charge, I had a senior nurse ask me to call the doc because the PA was wedged. (We are not covered to repostition PA catheters, but that's another story!!!) I went into the room and quickly identified that the PA catheter was out to about 18cm, and the sheath was filling with fluid infusing to the proximal port. The patient had just been turned for a linen change, and the PA had not been protected. It's not rocket science to critically troubleshoot that one!!!!

I find I am enjoying my teaching hours immensely, the students are so keen, and are basically empty slates at the moment. If I can help them to learn their skills without becoming task oriented, and somehow 'teach' them to be reflective, inquiring practitioners who think critically, which more often than not involves thinking 'outside' the box', I will feel that my time has been well spent.

Just my 2 cents worth!!

healingtouchRN · Sep 7, 2003

I can;t understand how someone can work in ICU for 20 years & not do CE's. They are required in this state, minimum 24 hours for re-liscensure. I have done more than 150 hours of CE this year alone. Maybe I just like going to school :rolleyes: but ICU changes perpetually, so CE is mandatory. Just my 2 cents worth!