Critical thinking at heart of being a good nurse

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Training, experience, observation and intuition are all part of the mix

This article was originally published in 2012.

To a patient, it may look like a nurse is touching a wrist, changing a bandage, reading a chart and asking random questions. What she’s also doing is thinking.

That nurse is assessing, listening, gathering information, prioritizing and planning the next action — all within minutes — often without being aware of all that she’s doing.

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Critical thinking is at the heart of being a good nurse.

“You start with the guidelines and theory that you know, and you build on that through your experience, but then there’s the human factor,” said Deborah Thames, RN, BSN, CCRN-CSC, a nurse scholar in the cardiovascular intensive care unit at Emory University Hospital in Atlanta.

Protocols may work 99 percent of the time, but when they don’t work for the hundredth patient, nurses must adapt to accommodate subtle or not-so-subtle changes, she said.

For Thames, critical thinking means applying everything she’s been taught, witnessed or experienced with all that she’s seeing and hearing at the bedside with a patient. She weighs benefits and risks while simultaneously prioritizing interventions to meet the most critical needs first, and then acts with confidence.

In emergencies, the process is seamless and swift — almost as if there’s no thought behind the actions.

“Critical thinking means pulling it all together to do what is necessary for the safest and best outcome for your patient,” Thames said.

As nurses assess priorities, some things they know can go to the wayside; others will have a huge, ripple effect.

“Taking care of a really sick patient is kind of like [working] a human puzzle,” Thames said. “The complex technology, machines, tubes, drains, medications, blood products, multisystem problems and difficult surgeries performed on our patients make it pretty intimidating sometimes, but also really challenging and exciting.”

Thames remembers a challenging case that perplexed the medical staff at Emory. A patient suddenly went downhill several days after open-heart surgery; doctors and nurses searched for postsurgery complications but found no answers.

Having seen it in a patient once before, Thames raised the possibility of an ischemic bowel.

“They examined the abdomen, did a bowel resection and saved his life. The doctor wrote to thank me,” Thames said.

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Nurses say critical thinking defies easy explanation; it’s simply part of who they are and how they do their jobs. We asked some nurses what it means to think like a nurse.

“A nurse has to be able to multitask, to think in several different directions at once. You start broad. You rule out the worst possibilities first and go from there. You use your education, but then you begin to see things over the years. People aren’t textbook cases. You have to care and be totally attuned to your patients and their families, so that you can be their advocate.

“We’re called on a stroke alert when a patient who is in the hospital for other issues starts to present symptoms of a stroke. When you place a carotid stent, for example, there are risks for complications. Two of these complications include ischemic stroke from thrombosis of the stent or dislodging plaque, or a sudden increase in cerebral blood, leading to hyperfusion syndrome and potential hemorrhage.

“You have to look at all the factors quickly, because giving TPA [tissue plasminogen activator] would help a clot, but it could increase bleeding to the damaged tissue.”

Susan M. Gaunt, RN, MS, CCRN, CNRN, Center for Neuroscience and Spine, stroke program coordinator, Gwinnett Medical Center

“Critical thinking means putting facts and feelings together in order to intervene for your patient. In nursing school we’re taught to put data together to create a plan of action, but numbers don’t tell the whole story. Even though a patient’s signs may be in the acceptable range, there’s that little voice in your head that says something’s not right. That comes with experience.

“I had a 6-month-old patient who had just had heart surgery. He’d been taken to a treatment room and his mother came to me upset because he had lost his IV and had no pain medication.

“I went to the room and could see he was in trouble. I called the charge nurse, picked up the infant and carried him back to the ICU, where they had a room ready. He arrested while we were replacing his IV, but because he was in the ICU he was being monitored and we could address his issues immediately, and he lived.

“If a parent is scared, there’s a problem. A parent is with the child every day and is the best source for baseline changes. Knowing when to listen comes with time and experience. The more experience you have, the more confidence you have to act.”

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Brenda Jarvis, RN, BSN, CCRN, resource nurse, cardiac intensive care, Egleston Hospital of Children’s Healthcare of Atlanta

“Nurses operate in what I call inherent nurse mode. When we see pain or a problem, we want to fix it. I’m always initiating the nursing process on the job and in life.

“You do an initial assessment of the situation, make a plan, implement the plan, evaluate it and make any necessary adjustments. You’re always anticipating the next thing that could happen.

“I had an end-stage cancer patient whose pain was not being managed. The medical team was still in the fix-it mode, but I suggested that palliative care could make him more comfortable. They took my suggestion, and it made a complete change in his attitude and behavior. His family was so grateful.”

Katrina Woods, RN, BSN, charge nurse, med-surge unit, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital

“As a nurse leader, I feel that to think like a nurse you have to be able to think about what is needed, prior to anyone asking. You have to anticipate your patient and family’s needs.

“A nurse’s way of thinking, I believe, is unique to the profession and the individual nurse. You have to always consider what may need to be done, and find creative ways to bring it to fruition, utilizing all available resources.”

Kaiya Valentine, MSN, RN-BC, unit director, cardiothoracic surgery unit, Emory University Hospital Midtown

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