Transcript Can You Teach Critical Thinking?

Can You Teach Critical
Thinking?
Or….
Why can’t they see what I see?
The Problem
• Increased demand on the nurse’s time
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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:
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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
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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
References
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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.
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.
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+Stra
tegy+SBAR+and+Other+Tools+for+Improving+Communication+Between+Careg.htm. Accessed
12/12/07.
Castle, A. Assessment of the critical thinking skills of student radiographers. Radiography 2006;
12:88-95.
Willingham, D. Critical thinking. American Educator 2007; (Summer): 8-19.
Ashcraft, A. Differentiating between pre-arrest and failure-to-rescue. Medsurg Nursing 2004;
13(4):211-216.
Clarke, S. Failure to rescue: lessons from missed opportunities in care. Nursing Inquiry 2004;
11(2): 67-71.
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.
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.