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  1. Hansten, Ruth I. MBA, RN
  2. Washburn, Marilynn J. MA, RN


Supporting staff to think effectively is essential to improve clinical systems, decrease errors and sentinel events, and engage staff involvement to refine patient care systems in readiness for new care delivery models that truly reflect the valued role of the RN. The authors explore practical methods, based on current research and national consulting experience, to facilitate the development of mature critical thinking skills. Assessment tools, a sample agenda for formal presentations, and teaching strategies using behavioral examples that make the important and necessary link of theory to reality are discussed in the form of a critical thinking test as well as a conceptual model for application in problem solving.


Taking a deep breath, the nurse manager stepped into the discussion, and after several calming attempts, gathered enough information to understand the situation. Shortly after midnight, one of the patients on the unit had began to deteriorate. His blood pressure was decreasing and he was beginning to complain of difficulty breathing. Martha, the nurse assigned to the patient, dutifully noted the change in condition and paged the on-call physician. When he did not respond within 15 minutes, and the patient's blood pressure was still lower, she paged again and charted her efforts. No clinical measures were taken; the charge nurse was not alerted. Martha waited again for the physician to answer the page. By the third unanswered attempt, the patient's blood pressure had bottomed out, and Martha called a code. The patient was transferred to the ICU shortly thereafter.


Upon reviewing the incident report and talking to Martha and the charge nurse, the nurse manager knew this situation required additional action. She picked up the phone and called the nursing education office, only to request, "You've got to do something with this staff! Is there some way to teach them to think?"


Sound familiar? No doubt as educators you have been asked more than once to assist in the correction of behaviors that led to a serious error or a sentinel event. The assumption by management is that this is an educational performance issue, and that you must have some ideas and strategies for improving clinical judgment and reducing the number of errors on any unit. You may sigh and face the challenge with more than reluctance, knowing that improving judgment is a much more difficult task than correcting performance based solely on knowledge deficit. For example, you remember that Stan is doing very well, and makes no more med errors after a session reviewing the metric system, but Karen is still unsure when to follow orders and when to question them. Her last error of administering IV furosemide when she knew the patient's potassium level was 2.2 raises the question as to whether she will ever learn to think.