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While not every decision is an immediate life-and-death situation, there are hundreds of decisions nurses must make every day that impact patient care in ways small and large.
“Being able to assess situations and make decisions can lead to life-or-death situations,” said nurse anesthetist Aisha Allen. “Critical thinking is a crucial and essential skill for nurses.”
The National League for Nursing Accreditation Commission (NLNAC) defines critical thinking in nursing this way: “the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief-based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research.”
An eight-year study by Johns Hopkins reports that 10% of deaths in the U.S. are due to medical error — the third-highest cause of death in the country.
“Diagnostic errors, medical mistakes, and the absence of safety nets could result in someone’s death,” wrote Dr. Martin Makary, professor of surgery at Johns Hopkins University School of Medicine.
Everyone makes mistakes — even doctors. Nurses applying critical thinking skills can help reduce errors.
“Question everything,” said pediatric nurse practitioner Ersilia Pompilio RN, MSN, PNP. “Especially doctor’s orders.” Nurses often spend more time with patients than doctors and may notice slight changes in conditions that may not be obvious. Resolving these observations with treatment plans can help lead to better care.
Some of the most important critical thinking skills nurses use daily include interpretation, analysis, evaluation, inference, explanation, and self-regulation.
These skills are used in conjunction with clinical reasoning. Based on training and experience, nurses use these skills and then have to make decisions affecting care.
It’s the ultimate test of a nurse’s ability to gather reliable data and solve complex problems. However, critical thinking goes beyond just solving problems. Critical thinking incorporates questioning and critiquing solutions to find the most effective one. For example, treating immediate symptoms may temporarily solve a problem, but determining the underlying cause of the symptoms is the key to effective long-term health.
Here are some real-life examples of how nurses apply critical thinking on the job every day, as told by nurses themselves.
“Doing a thorough assessment on your patient can help you detect that something is wrong, even if you’re not quite sure what it is,” said Shantay Carter, registered nurse and co-founder of Women of Integrity. “When you notice the change, you have to use your critical thinking skills to decide what’s the next step. Critical thinking allows you to provide the best and safest care possible.”
Often, nurses are the first line of defense for patients.
“One example would be a patient that had an accelerated heart rate,” said nurse educator and adult critical care nurse Dr. Jenna Liphart Rhoads. “As a nurse, it was my job to investigate the cause of the heart rate and implement nursing actions to help decrease the heart rate prior to calling the primary care provider.”
Nurses with poor critical thinking skills may fail to detect a patient in stress or deteriorating condition. This can result in what’s called a “failure to rescue,” or FTR, which can lead to adverse conditions following a complication that leads to mortality.
Nurses are the ones taking initial reports or discussing care with patients.
“We maintain relationships with patients between office visits,” said registered nurse, care coordinator, and ambulatory case manager Amelia Roberts. “So, when there is a concern, we are the first name that comes to mind (and get the call).”
“Several times, a parent called after the child had a high temperature, and the call came in after hours,” Roberts said. “Doing a nursing assessment over the phone is a special skill, yet based on the information gathered related to the child’s behavior (and) fluid intake, there were several recommendations I could make.”
Deciding whether it was OK to wait until the morning, page the primary care doctor, or go to the emergency room to be evaluated takes critical thinking.
Nurses have to use acute listening skills to discern what patients are really telling them (or not telling them) and whether they are getting the whole story.
“I once had a 5-year-old patient who came in for asthma exacerbation on repeated occasions into my clinic,” said Pompilio. “The mother swore she was giving her child all her medications, but the asthma just kept getting worse.”
Pompilio asked the parent to keep a medication diary.
“It turned out that after a day or so of medication and alleviation in some symptoms, the mother thought the child was getting better and stopped all medications,” she said.
“Critical thinking is present in almost all aspects of nursing, even those that are not in direct action with the patient,” said Rhoads. “During report, nurses decide which patient to see first based on the information gathered, and from there they must prioritize their actions when in a patient’s room. Nurses must be able to scrutinize which medications can be taken together, and which modality would be best to help a patient move from the bed to the chair.”
A critical thinking skill in prioritization is cognitive stacking. Cognitive stacking helps create smooth workflow management to set priorities and help nurses manage their time. It helps establish routines for care while leaving room within schedules for the unplanned events that will inevitably occur. Even experienced nurses can struggle with juggling today’s significant workload, prioritizing responsibilities, and delegating appropriately.
Another aspect that often falls to nurses is care coordination. A nurse may be the first to notice that a patient is having an issue with medications.
“Based on a report of illness in a patient who has autoimmune challenges, we might recommend that a dose of medicine that interferes with immune response be held until we communicate with their specialty provider,” said Roberts.
Nurses applying critical skills can also help ease treatment concerns for patients.
“We might recommend a patient who gets infusions come in earlier in the day to get routine labs drawn before the infusion to minimize needle sticks and trauma,” Robert said.
During the middle of an operation, the anesthesia breathing machine Allen was using malfunctioned.
“I had to critically think about whether or not I could fix this machine or abandon that mode of delivering nursing anesthesia care safely,” she said. “I chose to disconnect my patient from the malfunctioning machine and retrieve tools and medications to resume medication administration so that the surgery could go on.”
Nurses are also called on to do rapid assessments of patient conditions and make split-second decisions in the operating room.
“When blood pressure drops, it is my responsibility to decide which medication and how much medication will fix the issue,” Allen said. “I must work alongside the surgeons and the operating room team to determine the best plan of care for that patient’s surgery.”
“On some days, it seems like you are in the movie ‘The Matrix,’” said Pompilio. “There’s lots of chaos happening around you. Your patient might be decompensating. You have to literally stop time and take yourself out of the situation and make a decision.”
Allen said she thinks electronics are great, but she can remember a time when technology failed her.
“The hospital monitor that gives us vitals stopped correlating with real-time values,” she said. “So I had to rely on basic nursing skills to make sure my patient was safe. (Pulse check, visual assessments, etc.)”
In such cases, there may not be enough time to think through every possible outcome. Critical thinking combined with experience gives nurses the ability to think quickly and make the right decisions.
Nurses who think critically are in a position to significantly increase the quality of patient care and avoid adverse outcomes.
“Critical thinking allows you to ensure patient safety,” said Carter. “It’s essential to being a good nurse.”
Nurses must be able to recognize a change in a patient’s condition, conduct independent interventions, anticipate patients and provider needs, and prioritize. Such actions require critical thinking ability and advanced problem-solving skills.
“Nurses are the eyes and ears for patients, and critical thinking allows us to be their advocates,” said Allen.
Image courtesy of iStock.com/davidf
Last updated on Jul 24, 2024.
Originally published on Aug 25, 2021.
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Kristy Snyder Jul 24, 2024
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