Why Do New Grads Lack Critical Thinking Skills?

[LovingLife123]

I sit with my new grads after we get report in the morning and go over the whole patho of the patients we have and what we are looking for in assessments.  
 

Today our pt has a SAH.  This is why they are here even though they are a GCS of 15.  This is what could happen.  Our other pt is an ischemic stroke that got tpa.  Here is what can happen with tpa and why we do frequent assessments.  Then we talk about orders and what our patients need.  
 

It’s hard in the beginning because they are getting so much info thrown at them.  I will also quiz them a little.  

[Rose_Queen, BSN, MSN, RN]

I’ve been in nursing long enough to remember when the phrase du jour was clinical reasoning or clinical judgment. And it was always impressed upon the new nurses that sound clinical judgment comes from experience (and poor clinical judgment). 

In other words, they need the experience to gain it. Whether that’s in real life with their preceptor by their side (and not down the hall admitting another patient) or via classroom time reviewing case studies and scenarios. It seems like the expectation from the top down is that these new nurses can perform as though they’ve already got 2-3 years experience. The top needs to reset their expectations with a healthy dose of reality. 

[Wuzzie]

42 minutes ago, Rose_Queen said:

It seems like the expectation from the top down is that these new nurses can perform as though they’ve already got 2-3 years experience. The top needs to reset their expectations with a healthy dose of reality. 

This of course but have you ever oriented someone who just does not get it? I've oriented new grads whose critical thinking skills were top-notch and all they needed was to learn how to apply them to the nursing world. Then I've oriented people who could not critically think themselves out of a paper bag at the start and never improve. I sometimes wonder if the difference is in how they were parented. I see so many parents who never let their kids figure things out for themselves. I feel like it produces adults with minimal problem-solving skills and very little resilience. I feel bad for them.

[JKL33]

Maybe a side issue, but...it's hard to expect the world from a group where it is historically expected from the outset that elementary math is going to trip people up so they will require specific instruction and tutoring in "nursing math." That's basically selecting for a group that starts at a baseline way different than critical thinking.

And yes, beyond that ^ sort of problem, this is a role where being apprenticed and mentored would be very valuable, but it is an expense we are not willing to afford and thus a benefit we are not willing to ensure.

[Rose_Queen, BSN, MSN, RN]

53 minutes ago, Wuzzie said:

This of course but have you ever oriented someone who just does not get it? I've oriented new grads whose critical thinking skills were top-notch and all they needed was to learn how to apply them to the nursing world. Then I've oriented people who could not critically think themselves out of a paper bag at the start and never improve. I sometimes wonder if the difference is in how they were parented. I see so many parents who never let their kids figure things out for themselves. I feel like it produces adults with minimal problem-solving skills and very little resilience. I feel bad for them.

Experienced it many times and been involved in numerous performance remediation plans. I think it’s a combination of poor programs, people that just aren’t a match for healthcare, and previous life experience whether through parenting or what have you. 

[Hannahbanana, BSN, MSN]

The banner in the original said they should be trained more like “the medical model.” Fortunately for this NURSING community, that was not the focus of the actual discussion here. Better to have made an explicit case for better, longer orientations paired c expert nurses and keep the focus on nursing. Yes, I know that’s what happened, but why bring “medical” into it at all?

There is ample room for new nurses to grow and question in these examples— the temp, the K+, the drowsiness—but the last thing new nurses need is to have nurse experts imply that the “medical model” is the gold standard for nurse training and the critical thinking. Let’s just continue to call it critical thinking in the nursing process and do all we can to promulgate that. 

[JKL33]

2 minutes ago, Hannahbanana said:

but the last thing new nurses need is to have nurse experts imply that the “medical model” is the gold standard and the critical thinking that is the very heart of the nursing process is somehow lacking or subordinate.

This is interesting. I think that the nursing process and formulating care plans and all of that does help with, and represent, critical thinking.

We basically wash that out, negate it, bury it....with utter pettiness in nursing school. Every task that needs to be learned is a set of steps from which one must never deviate, and we'd rather watch people nervously shake their way through them than realize that "A" needs to be done and as long as you adhere to X, Y and Z principles you're good. All through our training it is like there is one right way to do every single thing and if you deviate it's like falling off a tightrope straight onto concrete, or the world is going to burn or someone is going to die. Well....we neither produce nor enable critical thinking with these methods that have long plagued this profession. And every time it is rumored that someone somewhere did something completely negligent....the rules pile up all the more.

How many "rights" of medication administration are there now? Nobody knows. It is whatever someone with a personality disorder said it is; that's how many.

[Wuzzie]

36 minutes ago, JKL33 said:

All through our training it is like there is one right way to do every single thing and if you deviate it's like falling off a tightrope straight onto concrete, or the world is going to burn or someone is going to die.

I avoid this approach like the plague and it has gotten me in some scuffles with our "educators". If I have an orientee that does something off-script all I do is ask their rationale for doing it differently and almost every single time they have a good one. On the rare occasion that they don't it's usually because someone taught them incorrectly in the first place and we have a discussion about the whys, hows and whatfors. 

[Natasha A., CNA, LVN]

Great article Nurse Beth!  I'm away from full time nursing, but still practice as a contract LVN. 

My two cents would be to stop calling problem solving skills as  "test taking strategies"  in the classroom. 

[Susie2310]

5 hours ago, Nurse Beth said:

New Grads Lack Critical Thinking ... Why?

Actually, it's expected and part of their development. Patricia Benner says new grads are in the Novice stage for about 6 months. Novices are rule-based and inclined to follow instructions without questions.

No Context

Melissa, a new grad, received her patient back from Surgery. The patient was an elderly female and accompanied by a PACU nurse. Together they transferred her to the bed and got her settled.

Less than thirty minutes later, the patient arrested. Later it was determined she was overly sedated. She was resuscitated and intubated but later died in the ICU. 

When receiving the patient, Melissa took her cue from the PACU nurse, who did not seem concerned at any point. Melissa had no prior experience assessing a post-op patient and did not know they can go from responsive to asleep in a short amount of time. She didn’t know that falling asleep in the middle of a sentence could be a serious sign of over-sedation and didn't know how a normal post-op patient looks. An experienced nurse would have checked in on the patient more frequently and would have been cognizant of the worst that could happen. 

It was devastating and Melissa quit nursing shortly after the incident. 

note: Unfortunately, her preceptor was down the hall admitting a patient from ED because the charge nurse and house supervisor saw the new grad as an "extra nurse" when they should have viewed the preceptor and preceptee as one working unit, not two.

No Sense of Urgency

New grads may lack a sense of urgency. Jennifer, a new grad, was passing meds when her hospital-issued phone rang. “Hello, this is the Lab. I’m calling about your patient Emma Nelson in room 325-1. Her potassium level is 5.8” Jennifer replied impatiently “I’m passing meds. Call me back in 30 minutes” and stuffed the phone back in her pocket.

To Jennifer, the most important thing is performing her tasks. To Jennifer's mind, she is successful when/if she can complete the list of tasks she's been assigned. She doesn’t yet see the big picture. For example, performing a patient assessment is a task, but she may not see how it drives the plan of care for the day.

A new grad doesn’t know whether a drop in urine output in a post-op patient is expected or if he/she should be alarmed. Will he/she get in trouble if they don’t call or ridiculed if they do? 

Limited Problem-Solving

Josh has been going into his patient’s room repeatedly to silence the IV infusion pump. He presses the silence key but in a few minutes it beeps again, so he goes back in and presses the silence key again. Finally, the preceptor goes in, pulls back the sheet, and tells the patient to straighten their arm. 

Later Josh’s nursing assistant reports a temp of 101 in one of his patients. Josh feels he should do something (maybe give Tylenol?) but doesn’t really stop to reflect what may be causing the elevated temperature.

Nursing school doesn’t prepare our new nurses for independent practice. New grads have book learning, and rules, but haven’t yet learned that patients don’t follow the textbook. Gray areas and ambiguity are difficult because they are comfortable with black and white thinking but can’t tolerate ambiguity.

They may have overwhelming anxiety and are very concerned about their performance. This leaves little bandwidth for reflection and problem-solving.

Critical Thinking

How can we help them develop critical thinking?

One way the preceptor can help is by answering questions with questions. 

• If a preceptee asks about a certain lab, say a high white count, respond with “What do you think about that?”
• Encourage them to journal and reflect. It’s really beneficial for a new grad to look back in their journal and see how far they’ve come since week one. 
• Ask them indications for medications when they are passing meds. Not just indications for the medication, but why is their patient is receiving the medication?
• After a provider rounds, ask them why the provider ordered a certain lab test, or discontinued a medication.
• Before calling a provider, ask them to anticipate what information the provider needs
• Before a procedure, use the What’s-the-Worst-that-can-Happen method: “So when we’re pulling that sheath/inserting that NG/removing that central line, what’s the worst that can happen?” 
• Follow up with “And then what will you do?”

It’s not helpful to tell a new grad to “trust your gut” because they don’t have a gut! It will only cause more pressure to now expect them to have a “gut feeling”. They do not yet recognize patterns or normals. They must recognize normal before they can recognize abnormal.

I think nurses should receive far more training before they practice independently, more along a medical model, with increased, supervised responsibility. Instead, after 12ish weeks of orientation, they are pretty much treated as a fully experienced nurse.

This isn't likely to change any time soon, so what we can do is help them develop problem-solving skills.

What ways have you found to help new grads learn to think critically?

I find the attitude that "Things aren't going to change anytime soon" very defeatist and problematic, when people with the power to make changes exist.  Is this passivity due to comfort with the status quo?  I'd like to hear more about why changes can't happen in a reasonable time period.

I think the above scenarios are a reflection of changes in nursing education over the last few decades.  In my view, without a good foundation for critical thinking in nursing school, using the Nursing Process, along with course work that covers pathophysiology, pharmacology, normal/abnormal lab values and actions to take, and actual hands on responsibility for providing care to hospitalized patients under the supervision of one's clinical instructor (the majority of nurses work in hospitals), including preparing care plans for the patients one takes care of in the hospital which are evaluated by one's instructor, new nurses lacking this basic foundational training in nursing never even reach the stage of being a novice.

As I see it, the examples given above don't just show new nurses who are lacking critical thinking; they show new nurses who are  inadequately prepared to be nurses and have no idea of what they are doing at the most basic level, and, worse still, who assume their nursing knowledge is sufficient to deal with the above situations and don't even think of making patient safety their first priority and ask for help from more experienced clinical staff (lack of humility).  

I think the whole process of nursing education today would benefit from being re-evaluated, especially in regard to students' hands on clinical preparation.  But I don't hear anything like this happening.  Why is that?  When I was a student, the vast majority of my clinical preparation, I.e. clinical rotations, was in hospitals, and all of it was in health care facilities, where we provided total care to patients under our clinical instructor's supervision.  It was unthinkable that a student wouldn't want to touch a patient, or that students would sit down during clinicals.  We didn't have Sim labs, or virtual clinicals; we practiced the clinical skills in the lab and were checked off for competency, and then we performed them in the hospitals under our clinical instructor's supervision.  Students graduated knowing how to use critical thinking skills I.e. the Nursing Process, and knew the basics of caring for patients, and when to ask for help.  

 

[Hannahbanana, BSN, MSN]

2 hours ago, JKL33 said:

I think that the nursing process and formulating care plans and all of that does help with, and represent, critical thinking.

We basically wash that out, negate it, bury it....with utter pettiness in nursing school. Every task that needs to be learned is a set of steps from which one must never deviate, and we'd rather watch people nervously shake their way through them than realize that "A" needs to be done and as long as you adhere to X, Y and Z principles you're good. All through our training it is like there is one right way to do every single thing and if you deviate it's like falling off a tightrope straight onto concrete, or the world is going to burn or someone is going to die. Well....we neither produce nor enable critical thinking with these methods that have long plagued this profession. And every time it is rumored that someone somewhere did something completely negligent....the rules pile up all the more.

..... and .....

30 minutes ago, Susie2310 said:

When I was a student, the vast majority of my clinical preparation, I.e. clinical rotations, was in hospitals, and all of it was in health care facilities, where we provided total care to patients under our clinical instructor's supervision.  It was unthinkable that a student wouldn't want to touch a patient, or that students would sit down during clinicals.  We didn't have Sim labs, or virtual clinicals; we practiced the clinical skills in the lab and were checked off for competency, and then we performed them in the hospitals under our clinical instructor's supervision.  Students graduated knowing how to use critical thinking skills I.e. the Nursing Process, and knew the basics of caring for patients, and when to ask for help.  

It doesn't have to be like this. I've posted this memory from my first day of clinical before (you can probably search for some of the content at http://allnurses.com/general-nursing-student/who-knew-my-754941.html), and I don't see any reason why every preceptor or staff development person can't say the same thing. Often.

..........

You just never know when the stars will align and you'll hear, see, or do something that will determine the rest of your career. I had a moment like that on my very first first clinical day, the day a gifted teacher taught me to think like a nurse.

Who forgets the first day of clinical? Even if you've been a CNA or a candy-striper, getting up and putting on that spandy-new student nurse uniform and shoes, walking into the hospital, and meeting your new classmates on your first floor is ... .

Oh, who are we kidding. Many of us don't remember a lot about our first days, really. Some had genuinely horrible experiences they laughed about later -- much later-- and most of us, meh, maybe not so much. But I did actually have a career-changing experience on my very first day of clinical, and if I haven't told you about it before, sit down a minute and indulge an old bat. It might surprise you. Heck, it surprises me even now.

We were sophomores in college. We picked up our uniforms at the downtown store the week before, individually, sight unseen; we dressed in the dark, and self-consciously made our way by subway or bus to the big hospital, finding the right building, riding the dark and creaky elevator to the sixth floor. We were excited but scared, with the usual wondering whether this was really the good idea it seemed a year --or gosh, a week-- ago. We assembled in the hall in front of the nursing station and met our instructor for the first time. We exhaled a sigh of relief when she smiled kindly at us, noticing that we had sort of been holding our collective breaths.

"Good morning. I am Mrs. Vartanian and I will be your clinical instructor on Colly Six." She read off our names alphabetically and peered at us over her glasses when we said, "Here" in small voices. She showed us the lay of the land and set us to passing out the breakfast trays, following up and down the halls looking for all the world like a big Rhode Island Red hen keeping an eye on eight chicks in the barnyard. After the trays went out she herded us all into the clean utility room. It was a cozy fit.

She showed us where things were, pointing out the various shelves: cath kits, gloves, wound packing supplies, liters of solutions. Then she picked up a huge brown glass bottle labeled "STERILE APPLICATORS" and unscrewed its lid. Applicators, we saw, were sorta like Q-Tips, but 6" long ones with wooden stems, cotton end down. About about a hundred and fifty of them, about an inch down below the lip of the glass. "How would you get one of these out without contaminating the rest of them?" she said.

Eyes looked rapidly right and left. Feet shuffled a little, quietly, those soft-soled so-white Nursemates. We had done a lab on sterile technique but this wasn't one of the things we practiced until our gloves were wringing wet inside. What to say? What if we get it wrong? What would happen to us?

Finally one of us said, hesitantly, "Pick one out with sterile forceps?" Mrs. Vartanian smiled and said firmly, "Good. Who can think of another way?"

Another way? What another way? We thought there was only one way to do any nursing task. Hadn't we just spent a week in lab getting each item on the check-off list perfect? But...she wanted us to think of another way. Slowly, we started thinking. "Sterile gloves?" "The sterile scissors in a suture kit?" "Try to tip one out onto a sterile field? Even if there was more than one?" And as each new answer came, she smiled and nodded.

Standing in the middle of the group I felt a terrific idea forming. It gave me goosebumps. We were free to think of different ways to do things, so long as we had a good rationale. No, that's not it: We had to think of different ways. Knowing the why of things, you know how to apply them. There can be another way.

And so ever since that day I've looked for different ways to do things. When I was an ICU nurse I thought about the many physiological processes going on so I could choose a useful intervention. When I taught students I tried to explain things in several different ways, figuring each student would catch on to at least one of them. When I did case management I thought about the why and how of the challenges of explaining to employers and insurance adjusters.

Now I'm in independent practice and I have different challenges. But you know, to this day it surprises me to feel goosebumps when I figure something out. I hear Mrs. Vartanian's voice just as it was that day, making me bold, defining my whole career in then-unknowable ways. "Who can think of another way?"