How Nurses’ Critical Thinking Reduces Errors, Improves Outcomes (Episode 30)

June 11, 2018

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Darcy Grabenstein: Hello from SmartLinx! In today’s podcast, we’ll talk about critical thinking in long-term care nursing: How to improve outcomes and reduce errors. Our guest today is Shelley Cohen, RN, MSN, CEN, who has written a book by the same title. Shelly is the founder and president of Health Resources Unlimited, a Tennessee-based healthcare education and consulting company. Her seminars for nursing professionals are designed to engage staff nurses and nurse leaders, assuring the best interests of the patient. She is also co-author of Essential Skills for Nurse Managers, and A Practical Guide to Recruitment and Retention: Skills for Nurse Managers. Welcome Shelley.

Shelley Cohen: Thank you, Darcy.

DG: Shelley, how would you define critical thinking for long-term care nurses? What are the key aspects?

SC: Well, it’s an interesting question because long-term care has certainly changed in its complexity of patients. And they’re now dealing with many more complex patients than ever before, so many more co-morbid diseases. They really have to have a mindset of almost a detective in many ways. And that all means that you can’t assume anything, you’ve got to constantly ask questions, and you need to be asking for some evidence before you accept any facts. So it’s really all about a very careful, a deliberate process, but it still has to be based on science or some other type of valid information, or even a best practice. But it all has to get wrapped up in a package related to the nursing process, where your skills and knowledge as a nurse and your experiences have to really superimpose everything else. And then the last piece of this is critical thinking does have a set of expectations. And within that, it’s not just the knowledge, it’s your ability to apply professional standards and ethics as you actually walk through this critical thinking process.

DG: Great advice. Thanks, Shelley. So how do nurses become critical thinkers? I don’t know if it’s innate. How long would you say it takes before critical thinking is really ingrained into a nurse’s thought process?

SC: You know this question, Darcy, comes up for debate a lot, and people can go on and on for hours with this debate on a panel of experts, etcetera. But what it really comes down to is, again, I’m going to go back to evidence. And what we know for sure is that it takes on average a registered nurse to go five years to transition from novice to that expert level. So it’s really unrealistic to expect a very high level of critical thinking in that novice nurse. We have to allow for that time to gain and garner those experiences, as well as the knowledge. Now, becoming and transitioning into this critical thinker happens also through your ongoing learning processes, the clinical experiences. But a huge impact comes from the preceptor and mentors you have along the way. Now what’s actually ingrained in the individual nurse is partly coming from the working culture that they’re surrounded by. You know, are they in a work environment where they’re supported with critical thinking, where they support ongoing knowledge. Is it becoming realistic for all of the staff to meet this minimal skill level related to critical thinking.

DG: Great. Shelley, tell us about some of the challenges that nurses face in incorporating critical thinking on the job. And would you say those challenges are the same or different for new versus experienced nurses?

SC: Well, this carries over a little bit, Darcy, from the previous question. So if we think of it in this way: Sometimes we have a new hire, maybe they’re an experienced person, maybe they’re a novice, and they’re going through your orientation process more quickly than ever expected. And you think, “Oh my gosh, in this person’s first life they must have been a long-term care nurse, they’ve got this down pat.” And then, compare that to experiences of nurses who are challenged going through your entire orientation, and they just seem to be stagnant and they’re not really able to move forward. So we see a variance in this, and you’ll also see this type of variance as you try to put nurses through different steps in engaging them in critical thinking. And once again, it is truly that work environment that becomes one of the greatest obstacles or challenges to move forward with critical thinking.

We need to have, and it’s imperative to have, nurse leaders and educators, preceptors, mentors that embrace this concept of critical thinking as well as ongoing learning, all leading to professional development. Now another challenge the nurse may face is that they don’t accept their responsibility for ongoing learning. Unfortunately, sometimes we’re engaged in a mindset where that nurse thinks, “Well if the organization that I’m working for thought it was important enough, they would send me, and if they don’t it’s not.” And we have to remind the individual nurse that it’s their name on their nursing license, not the name of the organization. So we need to make sure that the long-term care nurse as an individual professional is pushed and encouraged to have this ongoing development, so for example they know what we’ve learned about early identification of sepsis, and how to critically think through red flags and risk factors related to sepsis.

DG: Right. So, you know, isn’t it true though that nurses need CEUs, but are you saying that the continuing education doesn’t necessarily include that critical thinking component?

SC: Exactly. So just because I attend a class on sepsis and I get CE credit for attending in no way implies that I know how to apply that in the clinical setting of long-term care. I can sit through a mock code, but it doesn’t mean in a real situation when a client is going downhill, that I can properly intervene and I know how to prioritize airway first over getting an IV started, for example. And there’s been a lot of misunderstanding on the part of especially newer nurses to believe, “Well I’ve met my CE criteria for the year for my board, I’m good to go.” But in no way are they able to apply any of that information. And that’s why validating competencies should include methods to validate that they can apply critical thinking in their particular work environment.

DG: Got it. So what kind of work environment would you say, or work culture, promotes critical thinking?

SC: This has become, thank goodness, a new hot topic that a lot of organizations are really focusing on, in understanding the relationship between the work environment, not just on promoting critical thinking but also on patient outcomes and staff retention, which is huge in this day and age with issues related to the nursing shortage. So think about these things almost like a checklist to ask yourself if this does or doesn’t take place in your work environment. And you want to have these things there to help promote the critical thinking.

So the first item would be: Are there processes in place that actually actively encourage and reward ongoing learning?

Secondly: Is there zero tolerance for bullying at every level of the organization? And I’m not just talking about a zero policy in writing, I’m talking about are you practicing it.

Number three: If I walked onto your long-term care floor, would I get a sense that the work environment is happy and supportive among the team that’s working there? Or is everybody walking around with their head to the ground, going, “I wish I worked at Walmart because this isn’t a good place to work.”

Fourth: Are people really just busy with tasks, or are staff actually given the time to process critical thinking? You know, if I’m just going from task to task — I’ve got to give meds, I’ve got to get a Foley, I’ve got to get this guy up and walk — and I don’t have time to process those lab reports that just came back, with a low blood sugar or a high white cell count, then all those other tasks don’t really matter.

And the next item is: Are staff actually actively encouraged to try new things, processes that are going to improve the quality and efficiency of the care they give?

And then finally, probably the most important: Are the leaders and managers in place overtly seeking staff input on how they can improve that work environment or that work culture?

DG: Interesting. Shelley, you mentioned bullying. I mean, we hear about that in schools; I wouldn’t have thought about that in the workplace.

SC: Yeah, you know, it’s one of the most upsetting things for me as a practicing nurse. I’ve been a nurse for 42 years, and I still practice one to two shifts a week at a hospital here in Tennessee. And it is amazing that the profession continues to have this type of peer resistance, a mindset of “Well, you know, when I was getting out of school I just learned this on my own so you figure it out for yourself.” And you want to pull a Dr. Phil on them and go “How’d that work out for you?” Because you know, it didn’t work out good for them, nor did it for patient outcomes. And so we need to make sure that we really step up to the plate, support new hires, our current staff, and especially the new grads. The American Nurses Association even has a pocket card that you can download from their website, which is, that gives you scripted responses to carry with you when you’re verbally confronted by somebody with some type of inappropriate unprofessional behaviors or responses to you.

DG: Really, that’s interesting. You also mentioned a couple other things that I just wanted to touch on. The fact, obviously the nursing shortage, and then the fact that a lot of nurses are forced to work from a task-to-task basis. I mean, isn’t there a way around that? You know, given the nursing shortage, do nurses really have time to do critical thinking?

SC: It’s a question that challenges every type of nursing specialty out there, not just in the long-term care environment. But sometimes it’s just taking a step back. It doesn’t take more than a few minutes to look at a lab result and re-review, for example, a patient record or their history, and make that connection, you know, with those red flags. But if staff aren’t encouraged that it’s OK to do that, then they’re not going to take the time to do that.

And a lot of organizations have really resorted to what some people call a shift huddle, where they take three to five minutes at the beginning of each shift change and just some particular red flag is highlighted verbally, or they review with everybody, you know, we got a white cell count back on Mr. Jones in 541, it’s imperative that we prioritize rechecking his temperature, so I want to make sure a lot of techs know about that. And so getting that information out to the whole team. So there’s a variety of ways to do that, but if the organization doesn’t allow it and encourage it, the nurses won’t think it’s important either.

DG: Right. So, Shelley, how can managers evaluate nurses’ aptitude for critical thinking?

SC: Another good question, Darcy. So if we talk a little bit about going to that CEU class on sepsis but not really being able to apply that knowledge and show that you can critically think and make that connection on that individual patient, so there has to be some way that you can really evaluate this.

And one of the ways that is actually highlighted in the book is to use case scenarios. Now I think the best thing to do for long-term care, because you have such complex patients, is make case scenarios from the patients you currently have and identify what some of those red flags were, or information from the family, and follow along in the book and there’ll be a check-off list there on how to actually evaluate and validate that they can apply critical thinking.

Another way is to do self or peer chart, where at a certain point where people are coming in — maybe it’s once or twice a year for a skills day or a mandatory safety training — that they can be asked to retrospectively pull five or six charts, and have some specific criteria that you want them to actually review with critical thinking prompting questions on it.

And then another example, a third example, is a written assessment tool. You know, write out an actual multiple-choice quiz that has some critical thinking type questions, and again a lot of those examples are in the book.

DG: Why would you say is critical thinking so important for nursing staff and for long-term care facilities, especially in terms of the documentation that you just mentioned. With quality measures and five-star ratings on the line, how does critical thinking tie into all that?

SC: You know, it’s interesting. A lot of nurses have misperceived that “if I write down the vital signs on the chart, that implies that I critically thought what I should do about it,” and the answer is “No.” Or “if I take information from a machine” — maybe they have to do an EKG on a resident — “then it’s implied because I checked off that I did it, that whatever the results were, I sent through whatever the appropriate chain is.”

And this ongoing misperception about the responsibility to carry it to the next level of critical thinking becomes paramount when we look at malpractice litigation, and patients and caregivers that are wanting to litigate because of a lack of care. And when you go back and review the records, you want to find, as somebody trying to support the nurse and the organization, I want to look for evidence that somebody critically thought through. So they documented, they got a critical lab value on the chart, but there’s no documentation that they notified the PA, the nurse practitioner, or the physician, and then what action was taken in response to that.

So it becomes really hard to validate that staff are applying critical thinking if they don’t document it. If I catheterized a patient for a urine specimen, and there was no urine in the bladder, what did I do about it? Did I just not send the sample and document “unobtainable”? But that’s very concerning to have an empty bladder on a long-term care resident; what did that person do about it?

So this can become not only a regulatory or compliance-type issue, but also a risk management issue for the organization. We need to make sure that the long-term care nurse has the knowledge of risk factors, red flags, but also how do they put it in writing without having to feel like they’ve got to write an entire biography on every patient’s chart, which they’re not going to have time to do, how can they document things in a more succinct way. And for most nurses, regardless of their specialty, they have not had an updated documentation course since they got out of nursing school. So that has become an obstacle in applying and documenting that you can apply critical thinking.

DG: Thank you, Shelley, and I know you gave one example of a scenario. But do you have any other examples specifically for long-term care, where critical thinking would come into play?

SC: So besides that empty bladder when you catheterize the patient, we talked a little bit about the red flags for sepsis, we can also talk about the patient that is having an issue related to withdrawal. So a lot of new residents may have alcoholism as a disease, and their family is not aware and the patient is in denial. And you suddenly have a new admission in long-term care, and they got admitted typically during the day shift, and then it’s the night shift that finds out they have a patient with this acute change in mental status, and because of the patient’s age they’re assuming it’s related to a dementia disorder.

Always make sure, whenever you have a new mental change in a patient, regardless of their age, you must rule out that there’s an organic reason for it before you assume it’s functional or psychiatric in nature. And so we miss a lot of patients that are addicted to alcohol in the elderly population because we just don’t tend to think of that demographic having that disease process.

DG: No I wouldn’t have thought about that. Is that prevalent, have you found, in the industry?

SC: It is. And you know, we’re also seeing, unfortunately, as we look at suicide potential and depression, the rate for the male demographic, the highest rate is in the geriatric patients.

DG: Wow. Well thank you so much, Shelley, for sharing your expertise with us today. And to all our listeners, thank you for tuning in. If you’d like to learn more about Health Resources Unlimited, visit And if you’d like to learn more about SmartLinx and our fully integrated suite of workforce management solutions, visit us online at

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