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.
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If a preceptee asks about a certain lab, say a high white count, respond with “What do you think about that?”
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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.
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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?
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After a provider rounds, ask them why the provider ordered a certain lab test, or discontinued a medication.
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Before calling a provider, ask them to anticipate what information the provider needs
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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?”
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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?
2BS Nurse, BSN
703 Posts
"I agree with the medical model of training. New grads need progressive responsibility and supervision."
My nursing program basically threw us into our clinicals and it was "survival of the fittest". Why are medical students allowed to make mistakes and nursing students are not? I would have learned a lot more by observing a really competent nurse.