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Seasoned with Sage
No-Win Choices

What was I thinking?

What is the point of getting my Masters? After one class and I was ready to tell the tutor where to go.

"You haven't learned how to think critically," said Mrs. Crump.

"Ah, I'm still not sure what you mean by thinking critically," I said.

I'd been working in an east London hospital on an agency shift. I'd been left with eight acute patients, no handover, and a nurse assistant who called in sick. I was in the emergency room as well.

I complained, but like the typical nurse I pulled through the shift for the sake of the patients. I know I didn't do as good a job as the patients deserved, but there was just too much to do.

"You didn't deal with the situation as you should have," explained Mrs. Crump. "If you'd been thinking critically, and by that I mean taking control of your thinking and the situation, you would have made better decisions."

I shook my head. "So what was the right thing to do? Your explanation still hasn't helped me. I'm sorry; I just don't get it. I use common sense, and just try to do what is right. I did think of walking out but..."

I could have walked out, but as an agency nurse filling in a random shift, I'd have been in dire straits. The agency nurse always gets the blame and never has any real support when everything goes wrong.

Mrs. Crump is the typical nursing tutor--idealistic but not practical. She's probably never done an agency shift in a random hospital; they just didn't do it back in her day. I don't think she knows what it means to think "critically". It hasn't occurred to her that in some situations there is no right way, sometimes you just can't win no matter what you choose.

Bryn Hagan, RN,

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8 Responses to “No-Win Choices”

  1. Lea Says:

    Sometimes I feel as though there are senior RN’s who have gone into management a while back and lose touch with “being on the floor” or the times have changed and gone over their heads. These educators, tutors, academics have an ability to belittle and cause an RN to question their practice and as far as I’m concerned there are some which need to take a look at their “critique” and get some feedback of their own.

  2. Megan Says:

    Honestly, I think your hands were tied. You really can’t do much, because you are not a regular staff nurse. I am a regular staff nurse at a Pysch Hospital, and even now, I can’t even make a decision about running my shift without discussing it with management. Many times, they are not available. But, if we make a decision on our own, we can get in trouble for it. You did what you could, and management maybe needs to spend a few days in your shoes, so they remember what it is like.

  3. coleen Says:

    I’ve worked agency for four years and in a number of settings. It’s impossible for a staff nurse to sympathize with you because they don’t have to walk in cold to a new place, not knowing where a thing is and jump on board and do a good job without leaving feeling like you did a substandard job for your patients. The manager that was not supportive for you was the one not critically thinking when she assigned you an assignment that was too spread out. I find the more verbal feedback and the less hands on style of management belongs in the boardroom and not “on the floor in the trenches”. I recently had a nurse manager that instead of being helpful when three of my patients had Medical crisis’s at the same time try to divert my by giving me “the talk”, I stopped her in mid sentence and asked her what she could do right now to help me best was to get a full set of signs on a patient with a bp 68/40 while i give glucagon to my sugar crashing patient. It worked by being specific with what I needed.

  4. michelle ceo Says:

    I agree, with the comments made. Working in the trenches, is different, than idealistic paperwork. there are nurses i have met, that have been silenced so long that they have, just gone with the flow.No one wants to have the dunce cap on.Because I am new to the field,I can see the demarcation between old school, new school. Being specific works. Let’s bring all that we have to the clients. I am a nurse for the same reason all of us got here, healing.

  5. MK Says:

    I’ve read this over and over and still don’t see what she thought you should’ve done? Call the agency and tell them the staffing is unsafe and walk out?

    In the US, after taking report from the offgoing nurse; a nurse can lose their nursing license for abandoning patients.

  6. suki Says:

    I guess I’m not getting where the “tutor” was going with her critique? By the way what is a nursing “tutor” or is it an instructor (lingo used in your country?) But I’m stumped as to where she was going with it PERIOD.

  7. Diana Thornton Says:

    Some people get their nursing degree and go directly into teaching or management. They’ve never had a clinical experience. I had a nursing instructor who spent most of the clinical time talking to her boyfriend on the phone and thinking up ways to embarrass her students. I have managers who are basically persona non grata and utterly non supportive. They could be the three monkeys, see no evil, hear no evil. Speak no evil doesn’t apply because they talk about confidential matters involving staff members to their pets. These are our leaders????

  8. Kisha Says:

    I’ve had good nursing instructors, and then, I’ve had (I won’t say “bad”)distant instructors. My current Clinical educator has a motto. He says: Those who can’t teach . . . instruct. Instructors mean well. They want you to learn, but they often don’t have anything practical to give to you. They’re the ones who hands you a book and say go read it. A teacher will say, “let’s go do it”. Let me draw you a picture. How can I explain this so that you’ll ‘get it’.

    The reason I’m mentioning this in terms of education is because I’ve often heard this term “think critically.”

    This is something that is going around nursing school a lot lately. And, this is what they mean.

    The term “critical thinking” was first coined in 2003 by a person by the name of Chaffee. It was defined as “making sense of our world by careful examining the thinking process in order to clarify and improve our understanding.”

    The Alfaro – LeFevre model in (2004) summarized it further by stating that it:

    * Entails purposeful, goal directed thinking
    * Aims to make judgments based on evidence (fact) rather than conjecture (guesswork)
    * Is based on principles of science and scientific method
    * Requires strategies that maximize human potential and compensate for problems caused by human nature.

    These standards were determined to be too vague by a research group called The Delphi Research Project. So, they went on to characterize the ideal critical thinkier as:

    * one who is habitually inquisitive
    * well informed
    * trustful of reason
    * open minded in evaluation
    * honest in facing personal biases
    * prudent in making judgments
    * willing to reconsider
    * clear about issues
    * orderly in complex matters
    * diligent in seeking relevant information
    * reasonable in the selection of criteria
    * focused in inquiry
    * and persistent in seeking results that are precise as the subject and the circumstances of inquiry permit.

    Okay, all that sounds lovely right? But how practical is it for you when your patient is crashing, or you don’t receive the handoff report, or you are in a hostile, cold environment. Truth is, you don’t have a lot of time to “think”. In nursing, we’re often pointing out fires, rather than preventing them.

    Truth is, you probably already practice most of that stuff – if not all of it. The point is, you were accused of not thinking critically, but few leaders actually know what that means themselves. To me, if you did your best to meet your patients needs (in a very difficult situation), you had to have been thinking critically just to have made it through with both you and your patients in tact. We all have days where we just want to “walk out”, but we listen to reason. It’s not just about “fear of loosing our license”. It’s about why we wanted to be nurses in the first place. It’s about refocusing and bringing “humanity” back into our careers. Our patients need us – without us – they will not receive the care they need.

    However, back to critical thinking. The time to practice it, is NOT during crisis. The time to practice it, is when you don’t have patients crashing. Practice it before you even go to the floor. I know that when we leave our work place, a lot of us de – stress by putting work at work and home and home. And we need to do this, but it is often beneficial to review. This is where you can practice your critical thinking skills. It doesn’t have to take a long time.

    There are six steps to the critical thinking process.

    *Interpretation (categorization, decoding significance, and clarifying meaning
    * Analysis – examining ideas, identifying arguments, and analyzing arguments.
    * Evaluation – assessing claims and assessing arguments
    * Inference – querying evidence, conjecturing alternatives, and drawing conclusions
    * Explanation – stating results, justifying procedures, and presenting arguments
    * self regulation – self examination and self correction

    Take ten minutes. Maybe the subway home. Or in the bath or somewhere, anywhere to review your work. This doesn’t mean you “beat yourself up” over the things that went wrong. This means that you consider the challenges you faced.

    What was your interpretation of your actions? Were there problems that could have been prevented? Were your actions preventive or reactive? What was the outcome? What else could you have done in the situation?

    Were there arguments against what you did? Focus on specifics? If your skills were criticized by the supervisor or another nurse – what were their arguments? Don’t look at it as a personal judgment of “who you are”. Look at it as an opportunity for growth.

    Often, in nursing we tend to get defensive for many reasons. If upon reviewing the arguments against your care, you feel you could not have made improvements to it, then you can safely dismiss this. But, rarely will you ever find “perfect” care. We are only human.

    Still, by consistantly taking time to self evaluate and review these issues and consider what you could have done in a situation. You further the development of the “critical thinking” process. Then, during the next crisis, you remember “Oh, I can do this! Or “help” can be found here.”

    It’s not about simply “thinking”. We must always be thinking and competent practitioners. It is about improving our thinking process, so that we improve our patient care.

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