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 Clinical decision making Creative thinking Inquistive Mature Analytical Systematic Self Confident Truth seeking 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
Nursing Process 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. 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): 3. 4. 5. 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
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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