A Crisis in Critical Thinking PDF

A CRISIS in Critical Thinking D O R OT H Y D E L B U E N O W WHY CAN’T NEW REGISTERED NURSE GRADUATES THINK LIKE NURSES? Unfortunately , findings reported by the author in the early 1990s have not changed (1,2). Only 35 percent of new RN graduates, regardless of educational preparation and cr...

A CRISIS in Critical Thinking D O R OT H Y D E L B U E N O W WHY CAN’T NEW REGISTERED NURSE GRADUATES THINK LIKE NURSES? Unfortunately , findings reported by the author in the early 1990s have not changed (1,2). Only 35 percent of new RN graduates, regardless of educational preparation and credentials, meet entry expectations for clinical judgment. Although well versed in content, the majority are unable, or have considerable difficulty, translating knowledge and theory into practice. This article presents possible causes and potential solutions for the lack of critical thinking ability among nursing students. Since 1985, a valid and reliable competency-assessment system, Performance Based Development System (PBDS), has been used in more than 350 health care agencies in 46 states to assess nurses’ critical thinking and interpersonal skills ability. Reliability and validity of the assessment components have been reported in previous publications (1,2). In addition to being reported to each participating agency, annual assessment results are aggregated and interpreted by staff members at Performance Management Services, Inc. (PMSI). The aggregate data are used as benchmarks and to monitor patterns or trends. Table 1 displays aggregate results from 1995 to 2004 for experienced (more than one active year) and inexperienced RNs. Both ranges and mean averages are relatively consistent for both groups, giving further support to the system’s reliability. The percentages given for individuals meeting expectations are based only on critical thinking results. Because patient safety is given more weight in the assessment than customer satisfaction, interpersonal skill results are summarized but affect the final conclusion only when they are negative. Critical thinking, primarily as clinical judgment, is assessed using three patient-focused uncued exercises. Each exercise has a different level of difficulty and verisimilitude. The simplest exercise is a written, out-of-context series of patient and job events that evaluate the ability to determine the relative priority of each situation and effectively manage those that are urgent. The second assessment component, visual and out-of-context, evaluates the RN’s ability to accurately recognize and effectively manage peripheral intravenous problems. Application of aseptic principles is also included. The third, and most complex, contextual exercise uses a series of patient video simulations to evaluate the RN’s ability to: accurately identify patient problems; safely or effectively manage these problems in a relevant time period; and support actions taken with relevant rationales or logic. Although findings for all three assessment exercises are considered, assessment findings for the video simulation exercise, because of its verisimilitude, give the most weight to the final conclusion of acceptable or not acceptable. The Evaluation Process ABSTRACT Aggregate results for competency assessment of new registered nurses using the Performance Based Develop- ment System indicate that most new graduates do not meet expectations for entry-level clinical judgment ability. This article discusses implications for nursing education and offers recommendations for developing clinical judgment in nursing students. 2 7 8 Nursing Education Perspectives CLINICAL COMPETENCE Table 1. Performance Management Services, Inc. (PMSI) Assessments: relevant time period; and support actions New Registered Nurse Hires Meeting Expectations (percent) with a rationale. These expectations are EXPERIENCED INEXPERIENCED 22 hospitals 6,884 (62 percent) 3,536 (33 percent) 1 ambulatory Range 48 to 80 percent Range 12 to 61 percent 1995 through 2000 consistent and congruent with concepts described by Clarke and Aiken to support the need for more nurses at the bedside. Their article, “Failure to Rescue” (3), describes patient situations very 2001 11 freestanding hospitals 2,298 (63 percent) 1,100 (26 percent) similar to those assessed in PBDS in 7 systems Range 46 to 83 percent Range 12 to 55 percent which nurses did, or did not, intervene to reverse complications or problems not 1 ambulatory present on admission. 2002 Not only is it critical that nurses are 9 freestanding hospitals 3,200 (72 percent) 1,376 (35 percent) 14 systems Range 42 to 90 percent Range 13 to 67 percent 1 ambulatory present, they must make accurate decisions about what is happening, what needs to be done, how soon, and why. A trained hospital or PMSI employee com- 2003 24 freestanding hospitals 4,254 (68 percent) 1,766 (35 percent) pares the given responses to validated 10 systems Range 31 to 92 percent Range 6 to 64 percent criteria for each situation, summarizes findings for all assessment components, 1 ambulatory and determines a final conclusion for 2004 ability to meet expectations. The overall 78 hospitals 3,777 (66 percent) 2,210 (30 percent) conclusion ranges on a continuum from 1 ambulatory) Range 38 to 84 percent Range 3 to 56 percent unacceptable (unsafe) to expert (exceeds TOTALS 20,413 10,988 expectations). New RNs are expected to be at the entry (safe practice) point. Fol- Note.These data represent facilities implementing PBDS for the first time during the year indicated, plus clients rated by PMSI. All assessments validated by PMSI. The PBDS video simulations include patients for all clinical assignments (acute medical-surgical, intensive care adults and lowing the assessment, each individual receives an action plan that includes subsequent development and, if needed, reassessment after development strategies are implemented. neonates, perinatal, mental health, and perioperative). (The general medical-surgical patient situations are singular, actual, Findings What are the findings for the 65 percent to 76 per- physiological, overt and commonly occurring. They range from cent of inexperienced RNs who do not meet expectations for acute to emergent, and include gastrointestinal, genito-urinary, entry-level clinical judgment ability? Employers reasonably metabolic, cardiac, respiratory, and neurological problems.) expect inexperienced RNs to accurately recognize and/or syn- Because of limited clinical experience with any patient popula- thesize the patient’s clinical data or primary problem focus. tion, the general acute medical-surgical patient series is used, When the nurse is unable to do so, the patient’s problem is regardless of subsequent assignment, with inexperienced RNs unlikely to be safely managed. to validate already acquired critical thinking ability. As indicated previously, new employees are assessed for Analyses of 10 years of assessment data reveal several consistent limitations related to accurate problem recognition. their ability to accurately identify the primary problems or devi- Examples include the following: ations from normal health status; initiate independent and col- • At least 50 percent of inexperienced RNs conclude that a laborative actions to at least prevent further harm; act within a 24-hour postsplenectomy patient with acute, sudden onset of September / October Vol. 2 6 N o . 5 279 CLINICAL COMPETENCE right chest pain accompanied by severe shortness of breath and Table 2. Nursing Diagnoses Given in Assessments arterial blood gas results of respiratory alkalosis has only either • ALTERATION IN NUTRITION the latter or nonspecific “respiratory distress.” They treat this - For patients with acute abdomen/peritonitis, DKA, CVA emergent patient with only a paper bag to rebreathe carbon dioxide, totally ignoring the implications of the other clinical • RENAL FAILURE PATIENT - Mood change related to hospitalization as evidenced by poor nutrition - Agitation related to ICP as a result of fluid volume excess symptoms. - Inability to cope with illness and present condition due to active lifestyle • A second example is a patient post-head trauma and frac- • DIGTOXICITY PATIENT tured arm who exhibits, within 24 hours of the assault, overt - Ineffective individual coping related to various home treatments and decrease in mental status, bradycardia, and widened pulse pressure (elevated systolic, decreased diastolic pressures). Twenty-five to 35 percent of inexperienced RNs, who accurately note the vital sign changes, conclude “hypovolemic shock” medical regime - Noncompliance with medical regime related to advanced age and absent caregiver as evidenced by verbally stating confusion of schedule - Alteration in health maintenance, noncompliance - Learned helplessness with management relevant to systemic blood loss, but haz- • CARDIOVASCULAR ACCIDENT (CVA) PATIENT ardous for the actual patient problem. - Ineffective coping skills related to change in lifestyle as evidenced by • A third consistently found limitation is the inability to accu- depressed mood and appetite rately differentiate the cause of patients’ decreased urine output. - Alteration in sensory perception This symptom, regardless of other clinical data, is identified and - Diversional activity deficit related to long periods in bed managed as “fluid overload” with diuretic therapy. Many inexperienced RNs also attempt to use a nursing - Social isolation related to hip fracture secondary to hospitalization. • MYOCARDIAL INFARCTION (MI) PATIENT - Spiritual distress related to change in body function and appearance diagnosis for the problem focus. Whatever the original intent - Alteration in grooming related to frustration with operative site for its use, the results are at best cumbersome and at worst - High anxiety related to hospitalization risible. Examples of misuse of nursing diagnoses are displayed - Activity intolerance related to pain in Table 2. - Altered sleep related to constant interruption as evidenced by patient feeling Employers also reasonably expect inexperienced RNs, when managing patient health problems, to do the right thing for the right reason. Similar to problem identification, analyses of data anxious and restless • ACUTE ABDOMEN/RUPTURED BOWEL PATIENT - Altered coping mechanism related to hospitalization and exacerbation of chronic illness reveal consistent limitations. Examples include: inability to differentiate when and why diuretics are used; giving K-exalate Implications for Nursing Education Why are so many women to patients with elevated potassium levels regardless of cause; and men, bright enough to meet academic entry and exit require- anticipation of Vitamin K for patients with coagulation prob- ments and pass state licensing requirements, not able to accu- lems regardless of cause; indiscriminate monitoring of all vital rately identify and/or safely manage patients’ problems? Unfortu- signs without relevance or priority; and reluctance to initiate nately, there is no simple or single answer to answer this complex more than low flow (2 liters) oxygen for patients with severe question. Problem causes can be related to: changes in health respiratory distress. Additional examples of mismanagement care practices such as shortened length of hospital stays; sicker, are displayed in Tables 3 and 4. more acute patients; nursing education fads; and decrease in con- Analyses over 10 years consistently find no significant dif- tinuous clinical practice hours. Some nurse educators may claim ferences in clinical judgment ability based on educational that the cause is a different population of entering students with preparation or credential. The same ability ranges are found less ability or lower qualifications. The consistency of PBDS within diploma, associate degree, and baccalaureate graduates. reassessment findings, however, would not support this hypothe- The author does not believe that educators in any of these nurs- sis. RN graduates do possess potential ability to think critically ing programs teach such mismanagement, but somehow this is and make acceptable clinical judgments. what graduates have learned. 2 8 0 Nursing Education Perspectives This author believes that a highly probable cause is the CLINICAL COMPETENCE Table 3. Management/Actions Given in Assessments emphasis on teaching more and more content in the nursing edu- • Check blood sugar as it may decrease as body uses more to fight digtoxicity cation curricula rather than a focus on use of or application of • Insulin and glucagon to lower the blood sugar • Ambulate patient and do ROM to decrease BS (insulin was not given) • Give 2 units PRBC to counteract increased H/H (DKA patient) • Give antacid to decrease pH / Give bicarb to reverse alkalosis knowledge. A look at the size and plethora of nursing textbooks supports this conclusion. The PBDS model expects RN graduates to think at the appli- • Give heparin (to a patient accurately identified as thrombocytopenia)… cation, analysis, and synthesis levels of cognitive ability. Recall it will help him clot / Give anticoagulant to trick the body and stop bleeding and understanding of content, or selection of the correct answer, • Teach slow deep breaths to help kidneys compensate alkalosis (pulmonary do not equate to clinical judgment. Although a valid argument embolus patient) might be made for using the multiple-choice format in nursing • Assess eyeballs for fluid overload • Check ammonia level as patient is seeing yellow (digtoxicity) • Give oxygen to perfuse the kidneys course exams as preparation for the NCLEX-RN, students will also pass the licensing exam by determining why answers are • Give calcium gluconate to reverse digtoxicity “right” or “wrong” based on application of knowledge and logical • Give aminophylline to increase HR (digtoxic patient) reasoning. In the real world, patients do not present the nurse with • Ambulate patient (with acute abdomen labeled ruptured appendix) to a written description of their clinical symptoms and a choice of promote peristalsis written potential solutions. • Teach deep breathing to prevent hemolysis (pulmonary embolus patient) • Lower HOB as increased HOB could cause ICP to increase • Anti-diarrheal meds (for accurately labeled bowel obstruction patient) • Teach patient to blow nose with mouth open to decrease IICP Students need consistent experience with both visual simulations and real patients to learn how to effectively focus on and manage patient problems. Writing care plans does not substitute • Check (IICP) patient for bulging eyeballs for being there when complications occur. Knowing about does not • Give IV fluids with lasix for hypovolemic shock patient to replace lost equal making clinical decisions. Nursing is a practice art that fluids but not raise BP (patient actually has lowered HR and higher BP requires the use of knowledge within a specific set of circum- because of IICP) stances. Smart nurses are effective nurses when they think critically, not when they can pass multiple-choice tests. Table 4. Rationales Given for Actions in Assessments • Take IICP patient to bathroom so he can void thereby decreasing ICP • Bradycardia can cause hypovolemic shock Developing Clinical Judgment Contrary to common belief, • Give orange juice to increase platelets — because decreased platelets more education, particularly as part of content-focused nurse result in compromised immune system internships or residency programs, does not yield significant • Elevate the patient’s feet to increase venous circulation to the brain in positive results. Inexperienced RNs will learn to think critically order to decrease ICP only by expecting and rewarding them for doing just that, not • Patient is in alkalosis from not breathing enough hydrogen stating facts. • Elevated BUN/CR indicate liver problems • Respiratory alkalosis may indicate shock • Patient is breathing rapidly to exhale CO2 as a result of cardiopulmonary status due to dehydration As previously described in this article, each RN with unacceptable assessment PBDS results receives a follow-up plan based on the assessment findings. The plan can include development, • Liver function tests (for embolus patient) can indicate where it is clinical practice, and evaluation interventions. Development • Remove mashed potatoes from tray because potatoes have high K+ interventions are generally not attendance at didactic lectures or content (renal failure) teacher-driven courses, but, rather, individual or group participa- • Decrease CBI to prevent fluid overload (renal failure) tion in implicit questioning activities that require learners to • Strain the urine for size and number of ketones (DKA) • Monitor the postpartum patient with rectal pressure for pulmonary embolus apply, analyze, and synthesize knowledge for specific — usually visual — patient situations. Educators and clinical specialists • Give IV of NS to decrease the free-floating fat in circulation learn how to use these nontraditional strategies as a substitute for, (fat embolus/CVA) or enhancement of, content-focused sessions. • Check for facial swelling as this indicates risk of losing patent airway The most critical intervention needed, however, for improved September / October Vol. 2 6 N o . 5 281 CLINICAL COMPETENCE ALTHOUGH A VALID ARGUMENT might be made for using the nursing course exams as preparation for the students will also pass the licensing exam by “RIGHT” OR “WRONG” MULTIPLE-CHOICE FORMAT in NCLEX-RN , DETERMINING WHY ANSWERS ARE based on application of knowledge and logical reasoning. In the real world, patients DO NOT PRESENT THE NURSE of their clinical symptoms and a with a written description CHOICE OF WRITTEN POTENTIAL SOLUTIONS. Unlike traditional internships, which may last six to Table 5. Initial Clinical Judgment Assessment Results vs Reassessment Results 12 months, positive results on reassessments are Traditional Internships Initial Assessment (percent acceptable) Reassessment (percent acceptable) obtained on average for 70 percent of inexperienced Group 1 (n = 35) 23% 43% Group 2 (n = 45) 31% 38% Both experienced and inexperienced RNs are a Group 3 (n = 20) 25% 45% critical, but costly, component for health care agen- RNs within 10 to 12 weeks. cies. Competence assessment and development, expected elements of doing business, need to yield PBDS Strategies Used Group 1 (n = 43) 36% 83% an acceptable return on investment of time, dollars, Group 2 (n = 65) 28% 63% and resources. Although employers cannot expect Group 3 (n = 39) 36% 80% new RN graduates to be competent, they can rea- Group 4 (n = 15) 8% 75% sonably expect, upon graduation and licensing, a clinical judgment is clinical practice with a preceptor who practitioner who can meet safe entry expectations. This outcome coaches by asking questions, rather than giving answers or doing can be achieved by refocusing on both the art and science of nurs- the usual show-and-tell. Clinical coaches are provided with spe- ing. Like getting to Carnegie Hall, being an effective nurse cific questions to ask based on assessment findings. An example requires practice, practice, practice. is the quintessential or evaluative question: “What evidence do you have (primary/secondary source, objective/subjective) or About the Author Dorothy del Bueno, EdD, RN, is senior con- need to collect to determine the effectiveness of your interven- sultant, Performance Management Services, Inc., Tustin, Califor- tion?” This question needs to be asked every day in relation to nia. For more information, visit www.pmsi-pbds.com. different interventions for the same or different patients. These strategies work. Table 5 displays reassessment results for seven groups of inexperienced RNs. Four groups experienced Key Words Competence Assessment – Clinical Judgment – Critical Thinking – Patient Safety – Nursing Education PBDS competency-focused internships and three control groups attended traditional internships in hospital settings. All partici- References pants were initially assessed with the same general adult acute 1. del Bueno, D. J. (1990) Experience, education, and nurses’ ability to make patient video simulations and reassessed with different patient clinical judgments. Nursing & Health Care, 11(6), 290-294. situations that were relevant to their clinical assignment. 2. del Bueno, D. J. (1994).Why can’t new grads think like nurses? Nurse Educa- The PBDS competency-focused approaches do not require a specific group internship, but can be used with any individual. 2 8 2 Nursing Education Perspectives tor, 19(4), 9-11. 3. Clarke, S. P., & Aiken, L. H. (2003). Failure to rescue. AJN, 103(1), 42-47.