Class Helps Nurses ‘Step Up Their Critical Thinking’

Dealing with an acute patient population makes it challenging for nurses to look at the big picture because they are often busy with the task at hand – recording vital signs, ordering diagnostic tests, dispensing medication and so on.

“We get to be so task oriented that we sometimes forget to look at the whole patient,” says Joyce Brodnik, BSN, RN, CCRN, a clinical instructor at Cleveland Clinic’s Fairview Hospital. She adapted a critical thinking class originally taught at the health system’s Euclid Hospital to help nurses do just that. “In developing the class, we wanted them to start thinking a little differently,” says Brodnik, who team teaches the class with fellow clinical instructor Amanda Koehler, BSN, RN.

The four-hour class, entitled “Step Up Your Critical Thinking,” was originally offered to nurses on the telemetry unit at Fairview Hospital. Now held quarterly, the class is open to all the community hospital’s nurses. Staff from the catheterization lab, emergency department, step-down units and ICU have all participated. Each class is limited to 15 nurses to ensure everyone participates.

The class begins with a critical thinking exercise. Brodnik shares a long list of objects and asks nurses to memorize as many as possible in a short time. Then she asks attendees to write down the objects. Most people usually recall about six out of 25 items.

Next Brodnik says she will help the nurses change the way they think: She encourages them to classify items into groups. So, for example, if the list includes erasers, pencils and paper, those are all school supplies. Or items could be grouped by letter, so pans, pencils and peanuts would go under the “P” heading. Afterward, Brodnik gives nurses 15 seconds to examine the list of objects once again, then asks them to flip over their papers and name the items. Nurses typically name twice as many objects the second time around.

After this warm-up exercise, Brodnik and Koehler move into the heart of the class – teaching the nurses to use SBAR reports (Situation, Background, Assessment and Recommendation) effectively to ensure the best possible patient outcome. “We want the nurses to think ahead of time,” says Brodnik. “What do they need from the report? What is missing? Based on the report, how do they think the patient’s day will go? What complications might occur?”

The class covers several possible patient scenarios, including the following:

• A stroke patient with a history of atrial fibrillation
• A post-operative orthopaedic patient who develops shortness of breath
• A ventricular tachycardia patient who comes to the unit with diarrhea
• A patient with a hip fracture
• A patient with emphysema who had a myocardial infraction

Attendees take turns receiving SBAR reports for those patients from an ER nurse, then use the reports to think critically about how best to treat the patient. Based on the SBAR report, they discuss the following questions:

• What do you do first when the patient arrives on your floor?
• What abnormal signs, symptoms or assessment findings did you see?
• What are the potential complications for this patient?
• Do they require any urgent actions? Why or why not?
• What information needs to be communicated to the physician?
• What orders do you anticipate and why?
• After reviewing the physician orders, are there any issues that need to be addressed?
• What do you need to reassess?
• What type of patient education is necessary?

Brodnik admits to the class that this type of critical thinking – taking a proactive rather than reactive approach to patient care – is time consuming. “Your day may get busier,” she says. “But when nurses think critically and are prepared for possible complications, that definitely improves outcomes. Nurses will be on top of things.”