The Impact of Critical
Thinking
Michele Koss, RN, BSN, MS, CNML, CPHRM
And
Kathleen Visinski RN,MSN
Situation
 Infant
 Intensive Care Unit
 Cardiac
 Diaphragmatic hernia
 Oscillated
 Occipital pressure ulcer
Root Cause Analysis - RCA
 Promotes critical thinking
 Encourages examination of the whole situation
 The immediate task is usually not the issue
 Safe learning environment
Findings
 Really Sick Patient!!!
 Focus on physiology
 Could be turned, but not lifted
 Braden scale score
 Skin Team after development
 Not in the notes
 Really Sick Patient!!!
Critical Thinking
Cognition
Situational Awareness
Failure to
Validate/Verify
Mindset
Tunnel Vision
Patient Safety
“Patient safety is compromised when
nurses have underdeveloped criticalthinking skills, knowledge, and
awareness.”
Identified areas
 Test results
 Pressure ulcers
 Pneumonia
 Human milk
 Skin breakdown
 Medication
2016 Events
 Pressure ulcer
 Human milk
 Medication
Critical thinking
 Problem solving
 Analytical
 Clinical decision making
 Systematic
 Creative thinking
 Self Confident
 Inquistive
 Truth seeking
 Mature
 Flexible
 Open minded
Situational Awareness
 Unawareness or lacking knowledge of what is going
on
 To perceive that acts or conditions deviated from
desired path
Situational Awareness
 What do we want to happen?
 Recognize changes
 Utilize advanced problem-solving skills
Patricia Benner’s Model
Failure to Validate and Verify
 Failure to find or test the truth of something
 Failure in the cognitive process of establishing valid
proof
Failure to Validate and Verify
 What do we want to happen?
 Check with someone or something else
 Ask Questions
 Question answers
Mindset
 Primed or biased by pattern or preconceived notion
 A fixed mental attitude or disposition that
predetermines a person’s response to
interpretations or situations
Tunnel Vision
 The tendency to focus exclusively on a single or
limited objective or view
 Overly focused on details of the task
 Failure to see the big picture
Delay
 1. Failure to recognize
 2. Failure to intervene in relation to
 3. Failure to administer
Goal
Improve
critical
thinking
Empower
nurses
Process
• Nursing Process
• Recognition, Recording and Reviewing,
Reporting, Responding, and Rescuing
• Conceptualizing, Applying, Analyzing and
Evaluation
• Novice to Expert
• SOAP notes
Recognition v. Recall
 Nurses should not be required to memorize a lot of
information to carry out tasks. Memory load reduces the
user’s capacity to carry out the main tasks.
1. Externalize information through visualization
2. Concrete examples e.g. septic patient
3. Checklists to free up the nurse to critically think
Algorithms
 Two columns for novice to expert application
 “Required Action Steps” for all
 “Supplemental Guidance” when further information is
needed
 Three columns for multi-actor procedure
 Sequential action steps written with action words
 Cautions and notes placed before steps to which they
apply
 Job Aids
Prevention Elements:
Skin Assessment completed:
1.

2.
 Assess skin in contact with medical devices each shift or more frequently with other
care, Rotate pulse-ox probe at least every 8 hours or more often if able
Patient positioning (check documentation):

3.

At least every 24 hours but consensus best practice - recommend every shift
change (Q4H in perfusion compromised patients), Operating Room (OR) at end of
cases lasting 4 hours or more and/or on arrival PACU/ICU’s
Device Rotation:
Turn all immobile patients at least every 2 hours or timed with care in NICU (e.g.
standardized turning schedule, clock at bedside)
Maintain HOB less than or equal 30 degrees (unless medically contraindicated)
Note: Patients who are mobile and/or able to get out of bed may sit in a chair or
upright in bed if physically able to do so. Patient position must still be shifted
regularly to reduce pressure
Appropriate Bed Surface:
4.


Evaluate need for specialty bed based on Skin Risk Assessment
Use gel pads, pillows and/or pressure reduction device to cushion bony
prominences
Moisture Management:
5.


Barrier cream applied to create a moisture barrier for all diapered patients
Keep skin clean and dry
Reflection
 Apply knowledge to present situation
 Proactive debriefings
 Follow errors
 Follow near misses
Ideas
• Organizational support of a tool
• Experiential learning incorporated into high fidelity
training with self examination (reflective) periods
• Algorithms for specific populations, service lines
“Patient safety can be
directly affected by the
critical thinking of a nurse”
Goal
 Our goal is to improve the critical thinking of our nurses
and empower them to recognize problems, raise
questions, gather evidence to support answers and
solutions, evaluate alternative solutions, and
communicate effectively with others to implement
solutions for the best possible outcomes.
Four Strategies
 Hiring Process
 General Orientation
 Floor Orientation
 Ongoing practice
Hiring Process
 Specific questions can be
asked by Human Resources
and the managers to assess
a candidate’s ability to
critically think through a
problem.
General Orientation
 Central Educators adapted
many critical thinking case
studies and activities into
the orientation classes of
new staff.
Floor Orientation
 Preceptor competence
guide/scripting
 Why does this patient
need….
 How did you know the
correct way to perform this?
 How will you tell if the
procedure is helpful for the
patient?
Floor Orientation Cont
 Preceptor to identify a challenging patient scenerio or a
procedure not commonly performed, invite the new hire
to participate.
 What do you think is going on with this patient?
 Are you comfortable with the plan of care? Would you
recommend anything different?
Ongoing Practice
 Unit based care conference Does the plan of care reflect all of the identified issues?
 How is the patient responding to the current treatment
and nursing care
Conclusion
 There are many facets to critical thinking. We have
incorporated four ideas from various stages in a nurse’s
development. Each concept when incorporated utilizes a
viable strategy to improve critical thinking amongst our
staff nurses. Nurses need to be able to think critically to
face the challenges of today’s fast-paced, high tech work
environment and to ensure safe care to our patients
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Thank you for participating!
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