Critical Thinking

jjjoy, LPN · May 7, 2008

Pet-peeve alert. I think the term "critical thinking" is way over-used in nursing. Critical thinking can be applied in all different kinds of fields at all different levels.

The course you are planning sounds like a great course for new nurses! It would seem more accurate call it something like "clinical problem-solving" or "developing clinical judgement" or even "applying critical thinking to acute care nursing scenarios." I'll bet you're NOT explicitly teaching critical thinking skills, but are instead presenting scenarios where the new grads can practice pulling together information and using that to evaluate patient needs and priorities.

To call that "critical thinking" to me seems like calling an algebra "arithmetic" - not really incorrect but way too general to be meaninful. Pet-peeve rant over.

I hope your course goes well!!!

imanedrn · May 8, 2008

there are basic categories in which I'd like submissions:
patient safety issues
ethical dilemmas
prioritizing/delegating
BLS
mediation safety
end of life issues
misc

As a new grad, here are some of my thoughts on each topic, though I don't know if they answer your question directly.

This is a BROAD category, so narrow it down to a few topics that are most critical. The 2 that stand out most in my mind at this moment are falls and medications/errors. My experience with FALLS is that, although they are preventable, in confused patients, you can check on them, and not more than 5 minutes later, they are moving in a way that results in a fall. Of course, this results in a lot of tedious paperwork, and I still haven't learned how to prevent them. Then again, in my patients that haven't fallen, maybe I did do the "right" things to prevent a fall and, of course, didn't know what exactly it was / they were because the fall never happened! Regarding MEDICATIONS & ERRORS, we all know there is a plethora of information available. I think the emphasis should be placed on new grads truly understanding the severity of this issue. Fortunately, at my hospital, we use an electronic medication system which greatly assists us in accomplishing the 5 rights. In paper systems, however, I know checking and re-checking is critical.
So far, I've only experience 1 ethical dilemma that really cut me deep. I d/c'd a patient who had been experience severely high BPs during her hospitalization. The dr, case mgr, & social worker all knew that the patient did not have health insurance or the money to pay for her meds. The social worker actually said to me, "Yeah, I've talked to her already so many times. There's nothing more to say to her!" She took this "I'm so exasperated" approach with this patient, that I was so hurt to see a SOCIAL WORKER do this! Ultimately, I did everything I could to ensure the patient was safe before she left: I followed up w/ my charge nurse who told me to follow up with the case mgr who followed up w/ the social worker who did nothing. After that, although the dr had d/c'd her hours earlier, I contacted him about her high BP and if it was possible to keep her there or do something for her. He asked if case mgmt could arrange for her to have 3 days worth of free product (like that's going to help!) and give her clonidine 0.1 mg before leaving. I again followed up with my charge nurse, informing her that I didn't believe this patient was safe enough to be d/c'd & also mentioned what the dr said about contacting case mgmt for free samples. She said that case mgmt had already left for the day, and this should have been done earlier! (I did contact case mgmt earlier!). She said I did everything I could, so it was time to send the patient home! I've never felt so crushed about sending someone home in my life... I asked my co-worker (who was my preceptor) if she'd ever gone over the charge to the supervisor (which is what I really wanted to do!), and she no, but she'd considered it. In any case... that was my BIG ethical dilemma.
I believe that prioritizing & delegating can be taught, but it truly is not emphasized enough. While precepting, instead of my preceptor helping me learn how to prioritize, she always emphasized that I finished my charting first. If I wasn't finished, she would do ALL my extra tasks for me (from dressing changes, to calling docs, to verifying orders/meds, etc.). This was NOT good preparation for me! So, once I was on my own, I was really thrown into the deep end. Fortunately, I'm a fast learner, so I picked it up pretty quickly. However, I believe she should have challenged me to do these things on my own more. As far as prioritizing patients, I believe that is part critical thinking, part learned behavior. For example, this week I had a comatose patient who had to receive all her meds crushed via NG tube. I knew she was "safe," relatively speaking, so I gave her meds last. I've learned to get all my meds passed and charting done before anything else. This means that dressing changes, for example, are always done in the afternoon. As for delegating, this is learned also. Much of it involves knowing who will do what. I have one CNA who I've learned not to TELL to do anything. I always ask her if I can help with X task. If it's a tough bed-bath, for example, she'll say yes. Otherwise, she'll do the tasks on her own. I just realized that telling her to do things DID NOT work. I have another CNA who, when I approach this way, she always tells me that she doesn't need help with her job (in a friendly way, of course), but I always offer anyway!
BLS is NOT sufficient, in my opinion. You take a 4-8 hr class, and then have no REAL experience for the entire time the certification is valid. I'm terrified to think of how I'll react during my first code! I think it would help a ton if I could be present at someone else's code before my own. I'm planning on taking ACLS (even though it's not required for med/surg) just to have that extra training up my sleeve.
Mediation safety: I have no experience with this.
End of life issues: I haven't directly experienced this yet, either. As with BLS, I'd like to be involved in those of another patient before I have to experience my own. Getting a second-hand exposure, I believe, would help me considerably once I have my own patient issues to deal with!

I know that was a lot, but I hope it helps in some way! Thanks for taking the time to invest in this!

cardiaccare · May 8, 2008

Thank you Ranaazha, you brought up alot oof questions that new grads face. Its really scarey when everything is new - one of our goals is to help make some of these things so familiar that when they encounter something similar - they don't feel like they have to run out of the room to go be sick! Some of the things you bring up are so vital for new nurses and we want them to be better prepared!