The Impact of Critical Thinking

Transcription

1 The Impact of Critical Thinking Michele Koss, RN, BSN, MS, CNML, CPHRM And Kathleen Visinski RN,MSN

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3 Situation Infant Intensive Care Unit Cardiac Diaphragmatic hernia Oscillated Occipital pressure ulcer

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5 Root Cause Analysis - RCA Promotes critical thinking Encourages examination of the whole situation The immediate task is usually not the issue Safe learning environment

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7 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!!!

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10 Critical Thinking Cognition Situational Awareness Failure to Validate/Verify Mindset Tunnel Vision

11 Patient Safety Patient safety is compromised when nurses have underdeveloped criticalthinking skills, knowledge, and awareness.

12 Identified areas Test results Pressure ulcers Pneumonia Human milk Skin breakdown Medication

13 2016 Events Pressure ulcer Human milk Medication

14 Critical thinking Problem solving Clinical decision making Creative thinking Inquistive Mature Analytical Systematic Self Confident Truth seeking Flexible Open minded

15 Situational Awareness Unawareness or lacking knowledge of what is going on To perceive that acts or conditions deviated from desired path

16 Situational Awareness What do we want to happen? Recognize changes Utilize advanced problem-solving skills

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18 Patricia Benner s Model

19 Failure to Validate and Verify Failure to find or test the truth of something Failure in the cognitive process of establishing valid proof

20 Failure to Validate and Verify What do we want to happen? Check with someone or something else Ask Questions Question answers

21 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

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23 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

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25 Delay 1. Failure to recognize 2. Failure to intervene in relation to 3. Failure to administer

26 Goal Improve critical thinking Empower nurses

27 Nursing Process Process Recognition, Recording and Reviewing, Reporting, Responding, and Rescuing Conceptualizing, Applying, Analyzing and Evaluation Novice to Expert SOAP notes

28 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

29 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

30 Prevention Elements: Skin Assessment completed: 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: 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): 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: 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: Barrier cream applied to create a moisture barrier for all diapered patients Keep skin clean and dry

31 Reflection Apply knowledge to present situation Proactive debriefings Follow errors Follow near misses

32 Ideas Organizational support of a tool Experiential learning incorporated into high fidelity training with self examination (reflective) periods Algorithms for specific populations, service lines

33 Patient safety can be directly affected by the critical thinking of a nurse

34 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.

35 Four Strategies Hiring Process General Orientation Floor Orientation Ongoing practice

36 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.

37 General Orientation Central Educators adapted many critical thinking case studies and activities into the orientation classes of new staff.

38 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?

39 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?

40 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

41 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

42 Brier, J., Carolyn, M., Haverly, M., Januario, M., Padula, C., Tal, A., et al. (2014). Knowing 'something is not right' is beyond intution: development of a clinical algorithm to enhance surveillance and assist nurses to organise and communicate clinical findings. Journal of Clinical Nursing, 24, Carter, A., Sidebotham, M., Creedy, D., Fenwick, J., & Gamble, J. (2014). Using root cause analysis to promote critical thinking in final year Bachelor of Midwifery students. Nurse Education Today, 34, Chao, S.-Y., Liu, H.-Y., Wu, M.-C., Clark, M., & Tan, J.-Y. (2013, September). Identifying Critical Thinking Indicators and Critical Thinker Attributes in Nursing Practice. The Journal of Nursing Research, 21(3), Fero, L., Witsberger, C., Wesmiller, S., Zullo, T., & Hoffman, L. (2008, August). Critical Thinking ability of new graduate and experienced nurses. Journal of Advanced Nursing, Saintsing, D., Gibson, L., & Pennington, A. (2011). The novice nurse and clinical decison-making: how to avoid errors. Journal of Nursing Management, 19, Schaber, P., & Shanedling, J. (Spring 2012). Online Course Design for Teaching Critical Thinking. Journal of Allied Health, 41(1), Turkel, M., Marvelous, J., Morrison, D., & Singletary, B. (2016, July-August). Describing Self-Reported Assessments of Critical Thinking Among Practing Medical Surgical Registered Nurses. MedSurg Nursing, 25(4), Yoo, M.-S., & Park, J.-H. (2014). Effect of case based learning on the development of graduate nurses' problem solving ability. Nurse Education Today, 34,

43 Thank you for participating!

44 About Connecticut Children s Medical Center Connecticut Children's Medical Center is a nationally recognized, 187-bed not-for-profit children's hospital serving as the primary teaching hospital for UConn School of Medicine. Connecticut Children's is the only free-standing children's hospital in Connecticut that offers comprehensive, world-class health care to children; pediatric services are available at Connecticut Children's Medical Center in Hartford and at Saint Mary's Hospital in Waterbury, with neonatal intensive care units at Hartford Hospital and UConn Health, along with a state-of-the-art ambulatory surgery center, five specialty care centers and 11 other locations across the state. Connecticut Children's has a medical staff of nearly 1,100 practicing in more than 20 specialties. Connect with Connecticut Children s on Facebook, Twitter, Instagram, Pinterest and YouTube. For more information, please visit