Can You Teach Critical Thinking?

Or….

Why can’t they see what I see?

The Problem

• Increased demand on the nurse’s time– Higher acuities– Juggling multiple patient needs– Increased time away from the bedside– Fragmented documentation systems.

• Paper• Electronic

– Separate documentation for Physicians and RN’s– Mixture of novice and experienced RN’s– Inefficient hand-off communication between RN shift’s

Critical Thinking?

• Basic nursing education has focused on teaching critical thinking skills in the recent past.– Assumption is that Graduate Nurses possess

some of these skills– Reality – not universally evident

What the Research Says

Yes!• Can be taught in a

classroom setting.• Requires carefully

orchestrated lesson plans and evaluation

No!• You can teach maxims

of how someone ought to think, but without background knowledge and practice, they will not be able to apply the advice they memorized.

Critical Thinking?

• Assumption is that Experienced Nurses possess these skills

Patient Presentation

Mrs. C’s Case:Respiratory Distress S/P Open Cholecystectomy

(see handout)

The Situation

• Post-operative patient experiences a pre-arrest situation on an orthopedic surgical unit.– RN’s were unable to fully appreciate the potential for

respiratory insufficiency

– RN’s were ineffectual in critically evaluating the patient’s signs and symptoms until a rapid responses team needed to be called.

– Patient transferred to ICU

– Discharged home after 4 more days in hospital

The Strategy

• Hold a workshop to:– Strengthen RN’s skills in interpreting patient

data and to then apply appropriate nursing interventions.

– Develop communication systems to accurately relay patient data shift-to-shift.

– Help staff members to intervene in any other critical situation.

Bloom’s Taxonomy

• Benjamin Bloom– Educational psychologist– Developed Taxonomy of Educational

Objectives • Consisting of 3 domains: cognitive, affective, and

psychomotor

– Revised by Anderson and Krathwohl in 2001• Adds applications for teaching and evaluation of

learning activities

Workshop

• Present case study in a realistic manner

• Allow students to work through first 3 stages of the Cognitive Domain of Bloom’s Taxonomy

• Provide tools to assist in the discovery critical data.

Tools

• De-identified patient chart including:– Progress notes– Laboratory values– Physician orders– Operative reports– Radioilogy reports

• Blank graphic records• Blank shift-to-shift report sheets• Data Collection sheet

Shift

Areas of Concern:

Data to support any concern and interpretation of data (assessment, labs, nusing notes etc.)

Nursing Dx and nursing intervention needed? What?

 

 

Process

• Staff members were divided into groups of 4- 6• Lead in a shift by shift time frame• Staff to come to consensus in filling out worksheet• Document vital signs using ‘caret and dot’ method

vs. usual documentation of numbers only.• Fill in shift report based on data collected.• Shift by shift feedback provided by instructors.

Domains

• Knowledge – demonstrated by collection of objective data such as:

• Vital signs

• Nurse’s notes and nursing shift reports

• Medical orders

• Laboratory results

Domains

• Comprehension - demonstrated when staff determined which data to include on the data segment of the worksheet

• Application - demonstrated when a nursing diagnosis was formulated and area of concern identified.

Outcomes

• Staff compared their new shift-to-shift reports with actual shift-to-shift report

• Communication breakdowns in shift report were easily identified

• All staff were able to conclude that respiratory distress was an area of concern and appropriate nursing diagnosis.

Outcomes

• Staff practice committee took information from workshop and proposed the following changes:– Adopting SBAR method of communication– Changing vital sign documentation from

numbers based to caret and dot method of trending on graphic record.

Long-term Results

• No rapid response team calls for first 3 months after workshop.

• Charting of vital signs sustained

• Charting of vital signs adopted for the entire in-patient units

• Staff RN’s had tools that were user friendly

References1. Larkin, B G and K J Burton. (2008) Evaluating a case study using Bloom’s Taxonomy of Education.

AORN Journal, Sept, 88:3; 390-402.2. Goal 2 of the National Patient Safety Goals 2007; Communication.

http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_hap_npsgs.htm. Accessed on 12/12/07.

3. Institute for Healthcare Improvement: Effective teamwork as a care strategy – SBAR and other tools for improving communication between caregivers. http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/Effective+Teamwork+as+a+Care+Strategy+SBAR+and+Other+Tools+for+Improving+Communication+Between+Careg.htm. Accessed 12/12/07.

4. Castle, A. Assessment of the critical thinking skills of student radiographers. Radiography 2006; 12:88-95.

5. Willingham, D. Critical thinking. American Educator 2007; (Summer): 8-19.6. Ashcraft, A. Differentiating between pre-arrest and failure-to-rescue. Medsurg Nursing 2004;

13(4):211-216.7. Clarke, S. Failure to rescue: lessons from missed opportunities in care. Nursing Inquiry 2004; 11(2):

67-71.8. Su, WM, Osisek, PJ, Starnes, B. Applying the revised Bloom’s taxonomy to a medical surgical nursing

lesson. Nurse Educator 2004; 29(3): 116-120.9. Su, WM, Osisek, PJ, Starnes, B. Using the revised bloom’s taxonomy in the clinical laboratory –

thinking skills involved in diagnostic reasoning. Nurse Educator. 2005; 30(3): 117-122.