Critical Thinking in Nursing

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Critical Thinking in Nursing

• Sheryl Abelew MSN RN

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Priority Setting

• Chapter 4

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Priority Setting

• Important step in the critical thinking process
• Includes effective time management
• Steve Covey (1989) states you should be putting
  first things first. There are three categories
  must do, should do, and nice to do.
• Develop a time frame for priorities.
• Review box 4-2 Time Management Procedures

4
Prioritizing patient needs

• Use Maslows hierarchy of needs
• Five levels of needs
• Physiologic needs
• Sleep, food, water, movement, comfort
• Psychological needs
• Safety and security
• Love and belonging
• Affiliation, affection, intimacy
• Self-esteem
• Sense of self worth, self respect, dignity
• Self-actualization
• Recognition of potential growth, health, autonomy

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Prioritizing Nursing Diagnosis

• Place in level of priority High, Medium, and Low
• High
• Life threatening, threats to pt safety, pain, and
  anxiety, unstable or changes in condition
• Medium
• Problems that could result in unhealthy
  consequences, like emotional or physical
  impairment, but no threat on life
• Low
• Problems that can be resolved with minimal
  intervention and have little potential to cause
  dysfunction

6
Priority Activities

• Four levels of priority according to Rubenfeld
  and Scheffer (1999)
• Life Threatening Issues
• ABCs
• Safety
• Protecting the patient from injury, practicing
  within scope of nursing, doing no harm
• Patient Priorities
• Plan of care based on patient activities and
  condition
• Nursing Priorities
• Examine all the patients strengths and health
  concerns, moral and ethical and Maslows
  hierarchy of needs

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Multitasking

• Setting priorities is not linear
• Addresses multiple concerns at the same time
• Learning to take charge and make efficient use of
  time is key in time management
• Making a to do list will help with multitasking

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Prioritizing within the nursing process

• Assessment
• Obtain complete information and sort and ID
  problems
• Analysis
• Prepare list of needs and diagnosis
• Outcome Identification
• Have measureable goals based on Maslow, and
  prioritize diagnosis
• Plan
• Select diagnosis and activities
• Implementation
• Perform immediate actions to prevent harm first.
  Highest priority to lowest priority
• Evaluation
• May require reevaluation and/or adjustments

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Pitfalls in priority setting

• Priorities may change
• Inadequate assessment of clients needs
• Failure to differentiate priority and non
  priority tasks
• Accepting others priorities without seeing the
  big picture
• Performing tasks that were identified first vs.
  those that are a priority
• Completing the easiest task first instead of the
  priority

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Nursing Process Applications

• Chapter 5

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Nursing process

• Nursing Process is considered to be a
  specialized form of systematic inquiry or problem
  solving process used in drawing conclusions about
  the patients problems and the corresponding
  nursing actions to resolve problems. Saucier,
  Stevens Williams (2002).

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Role of Nursing Process

• Allows for a consistent use of standards and
  standardized language providing for a way to
  measure and quantify the effects of nursing care
  and interventions
• In order to keep terms consistent, ANA recognizes
  NANDA as the official language of nursing
  diagnosis, NIC for interventions classification,
  and NOC for outcomes classifications

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Steps of the nursing process

• Assessment
• Analysis (Diagnosis)
• Outcome Identification
• Plan
• Implementation
• Evaluation

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Assessment

• Collect data
• Identify pertinent data
• Recognize deviations from normal
• Validate data
• Sort and Organize data in a logical order
• Identify patterns in the data

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Analysis

• Examine for unmet needs and strengths and health
  concerns
• Focus on problems the nurse can change
• Develop diagnosis based on facts
• Validate the diagnosis
• Establish priorities

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Outcome Identification

• Establish outcomes
• Realistic
• Achievable
• Measureable
• Collaborate to review goals to meet needs

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Plan

• How to develop your strategies for meeting
  nursing interventions
• Use NIC for nursing interventions
• Write plan of care using standardized language
• Collaborate for planning delivery of care

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Implementation

• Initiate actions to accomplish goals
• Manage care in order of priority
• Delegate care based on caregiver, acuity, needs
  and plan of care
• Intervene as necessary
• Document interventions and response

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Evaluation

• Compare actual vs. expected outcomes
• Communicate findings
• Record attainment of goal
• Review and modify POC based on needs

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Care Plan

• Written documentation of the nursing process
• See Box 5-3 for care plan formation
• See Table 5-5 for sample care plan scenario

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Delegation

• Chapter 6

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Delegation

• Transferring tasks to a competent individual
• Used most commonly with a skill mix based on
  scope of practice
• Consider job description when delegating

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5 Rights of delegation

• Right Task
• Right Circumstance
• Right Person
• Right Direction and Communication
• Right Supervision and Evaluation

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Obstacles of delegation

• Delegator reluctant to take the risk and give up
  control
• Subordinate fails to take responsibility
• Workplace issues

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Delegation Procedure

• Assessment
• List patients need and assessment findings
• Analysis
• Level of care and acuity
• Outcome identification
• Establish priorities
• Plan
• Nurse specifies nature of tasks and skill
  required
• Implementation
• Delegation of tasks
• Evaluation
• Compare outcomes with the POC

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Communication

• Chapter 7

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Levels of Communication

• Three levels of Communication
• Social
• Interactions for building relationships
• Therapeutic
• Nurse listens to patient problems and focuses on
  needs
• Collegial
• Enhancing relationships with colleagues, improved
  pt care, and better documentation

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Collaboration

• Nursing Personnel
• Delegating
• Report
• Interdisciplinary
• Conflict resolution
• Physician notification
• Receiving phone calls

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Written Communication

• Documentation
• One way to validate critical thinking
• Keep confidential
• Accurate and objective
• Performed promptly

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Patient Teaching

• Chapter 8

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Applying the nursing Process

• Goal directed based on rationale thought
  processes
• Involves critical thinking
• Approached analytically

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Learning needs assessment

• 4 areas must be assessed
• What the patient needs to learn
• Characteristics of the patient
• Patients preferred learning style
• Whether patient is ready/willing to learn
• Conduct a learning needs assessment
• Assess cultural background
• Developmental stage consideration
• Literacy

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Processes

• Analyzing needs
• Validate with the patient
• Outcome identification
• ID goals, clear objectives
• Planning the lesson
• Instructional methods
• Traditional i.e. lecture, discussion
• Non traditional i.e. role-playing, simulations,
  etc
• Implementing educational session
• Evaluating the educational process

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Applying clinical reasoning to various practice
settings

• Chapter 9

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Reasoning

• When processing data, continually evaluate
  reasoning
• Examine the evidence to determine what else is
  needed
• Obtain and clarify data
• Examine logic and give reasons for conclusions
• Review the consequences of possible actions and
  draw conclusions if desired outcome can be
  obtained

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Guidelines for decision making

• Use professional standards as guidelines to
  decision making when evaluating patient
  circumstances, and then consider the textbook
  data, current diagnostic test findings, and
  assessments of the nurse
• Nurses need to follow the regulations set forth
  according to scope of practice and standards of
  practice as well as the code of ethics for nurses
  when making decisions
• Review box 9-2 pg 199

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Application of cognitive skills

• Nurse collects information and uses skill of
  interpretation to define what the patient is
  presenting as
• Nurse establishes expected outcomes for
  interventions to determine if the problem will be
  resolved
• After implementation, nurse will evaluate on an
  ongoing basis progress towards goals
• After recognizing effects from intervention,
  nurse will offer rationale for the result
• Lastly, nurse will reexamine thinking

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Clinical Reasoning applications

• Quality implies evaluation
• Evaluation requires standards which define the
  acceptable levels of care
• Nurse must evaluate actions to the professional
  practice standards from the ANA

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Evaluating the workload

• Indicators that identify impossible workload
• Failure to monitor when indicated by patients
  condition
• Inadequate treatment for circumstances
• Excessive delay of treatments
• Failure to provide ongoing care and treatments
• Lack of time to provide patient teaching

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Monitoring patient condition

• Use clinical reasoning to monitor patients change
  of condition and respond with the appropriate
  intervention
• Two examples of monitoring the patients condition
• Calling the physician
• When there is a change in condition
• Pain without ordered meds that manage the pain
• Acute elimination problems
• Lab values that require orders
• Risk to safety
• Interpreting lab values
• Are the findings abnormal and expected
• Are the findings abnormal and unexpected
• Are the findings normal

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Pitfalls in clinical reasoning

• Failure to use appropriate decision making skills
• Failing to assess, report, or omissions
• Failure to assess for changing of condition
• Nurse fails to perform duties appropriately
  results in negligence

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Ethical decision making

• Chapter 10

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Ethics

• Ethics deals with the principles of right and
  wrong
• Foundation of ethics is standards of conduct and
  moral judgment
• Nurses must be aware of their own value system

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Model of ethics

• Choosing
• Allows for free choice identifying alternatives
  and selecting alternatives
• Prizing
• Individual satisfaction with choice of
  verbalization to others
• Acting (Internalization and repetition)

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Ethical Guides

• Ethical Principles
• Autonomy
• Right to self-determination
• Nonmaleficence
• Directs the nurse does no harm
• Beneficence
• Doing good on the patients behalf
• Justice
• Moral obligation to treat people fairly and
  equally
• Fidelity
• Keeping your word and acting in the patients
  best interest
• Veracity
• Telling the truth

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American Nurses code of ethics

• ANA as developed a code of ethics
• Nine statements define this code
• Review pg 233 Box 10-3

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Ethical decision making process

• Assessment
• Analysis
• Outcome Identification
• Plan
• Implementation
• Evaluation

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Assessment

• Gather information to determine the facts that
  will have the most affect on the situation
• Develop sensitivity to recognize ethical
  situation and its essence to nursing
• Identify risks to the patients

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analysis

• Determine the values in conflict
• Become aware of the relevant information
• Values clarification
• Generate multiple alternatives and rank in order
  of what is right and wrong
• Explore emotional, social and physical risks to
  patient and staff

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Outcome identification

• Providing safe nursing care
• Expected outcome should serve as a guide in
  making decisions
• Use clearly stated outcomes for success to be
  measureable

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plan

• Decision maker should choose the best options for
  prioritizing of needs to achieve the desired
  outcome
• Organize information and alternatives that
  represent various moral views
• Be prepared to defend your choice
• Stay focused on the outcome to stay focused on
  the real problem

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implementation

• Implement the moral action selected to resolve
  the dilemma
• Follow chain of command
• Support a blame free environment

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evaluation

• Were the actions ethical?
• Did the solution generate the desired outcome?
• Can you justify the consequences?
• Do the benefits outweigh the risks?

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Ethics committees

• Hospitals and long term care facilities have
  groups of individuals who discuss, clarify, and
  resolve issues related to patient care welfare
• Goal is to support objectivity in difficult
  patient care decisions
• Best when whole team and patient and families are
  involved

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Frequent areas of dilemma

• Self-Determination
• Professional Caregiver Issues
• Risk for injury
• Usually with the demented, depression, or
  delirium
• Inadequate staffing
• Staffing appropriate for acuity of patients
• Nurses practicing out of their specialty or
  knowledge base
• Biomedical advances
• Transplants, in vitro, etc.

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Pitfalls in ethical decision making

• Disregard for others
• Using others without considering them
• Inappropriate application of standards
• Making decisions that another prudent
  professional would not make
• Personal gain
• Having ulterior motives
• Conflict of values
• Responding to needs without concern for those
  affected

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Applying nursing judgment in clinical settings

• Chapter 11

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judgment

• A skill required in choosing how to meet the
  needs of a group of patients
• Requires
• Problem solving
• Priority setting
• Decision making
• Good application of the nursing process
• Ability to identify variations in patients
• Strong knowledge base
• Sound nursing decisions

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Establishing what to do first

• First level priorities
• Life threatening
• Unstable, worsening of condition
• Second level priorities
• Delay may cause untoward results
• Nonemergent
• Scheduled meds, mental status changes, acute pain
  
• Third level priorities
• Deficits that can easily be resolved or do not
  affect normal function
• Bathing, grooming, emotional support

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Determining what needs to be done

• Review implications if care/treatment were to be
  delayed
• Develop and action plan
• Scheduled activities should be primary
  consideration
• Determine who can do it
• Consider the roles of available UAP
• Evaluate competency of staff

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Float nurse

• Nurses should not refuse because of a lack of
  skill
• Focus on what they can do and what they can help
  with being supervised
• Educational preparation is ideal
• Review pg 264 Box 11-3
• Review pg 264 box 11-4
• If an assignment is out of scope of practice
  submit an occurrence report and request
  additional training

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Specialty nurse skills and competencies

• ED nurses
• Coronary intensive care nurses
• Pediatric nurses
• Obstetric nurses
• Oncology nurses
• Psychiatric nurses
• Medical/surgical nurses

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Room assignment process

• Consider circumstances and need
• Gender
• LOC
• Acuity
• Special needs
• Age
• Medical dx
• Staffing
• Family requests

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Pitfalls in nursing judgment

• Failure to use nursing judgment
• Inability to gather data
• Inadequate decision making
• Inability to prioritize
• Incompetent application of cognitive skills
• Failure to ID impact of action on an outcome