Developing Critical Thinking in Teams

It feels like there is something missing.  "How did they not see this patient was becoming more unwell?", "I can't trust anyone to do their job".

We tend to think we think with logic at the forefront, but as this episode unpacks all of us have flawed, clouded with emotions and biases.  In this episode Tubi and Naomi unpack critical thinking and developing it in out nursing teams.  

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Transcript

SPEAKER_02 0:29

The term critical thinking keeps coming up over and over. Our leaders are asking, why aren't our nurses critically thinking? Today, Tubi and I step into unpacking what that is, how we can foster it, and what things you can do to help develop it in your teens. Welcome to Better Every Shift. I'm Naomi, and together with Tubi we unpack difficult conversations. Today we're talking about critical thinking and clinical judgment and how do we improve this in our teams. What things are missing and what things can we add to make our lives just that little bit simpler. Enjoy the episode. Alrighty. Welcome back. Clinical judgments. I've been doing work recently around the way that we do clinical judgment, and I'm keen to know from you what comes up for your teams, what concerns get raised by leaders that you hear about when people are talking about people's clinical skills and clinical judgment and what that's like in the clinical space at the moment.

SPEAKER_00 2:10

Is that they're not joining the dots between what they're seeing and what it could mean. So they an example might be they're doing a blood pressure, they're doing ops, and the blood pressure is really low and the heart rate is really high, and they're recording it dutifully, and they're going back an hour four hours later and they're doing it, and attempts up, blood pressure's low, heart rate's high, they've recorded it beautifully, but that's the extent of the action. They haven't gone. What is this information telling me? And what's the action I need to take as a result?

SPEAKER_02 2:48

Yeah. And what actions are educators, managers, leaders in the space, what actions are they trying to take to rectify that? What happens in the services?

SPEAKER_00 3:03

Uh I think this is where the conversation gets really hard because sometimes managers, leaders, supervisors, senior staff are frustrated because their expectation is here, they should be making joining those dots. But the reality is they're not joining the dots, and they're caught in frustration because it feels so overwhelming with everything else they have to do. They feel like they have to go to every person on the shift and like double check. And so what I see actually happens a lot of the time is micromanaging because they're scared that the person will have missed something or not even asked a question. Hey, their blood pressure is lower than it was yesterday. What do you think that means? It's not just that they're not joining the dots, they're not asking the questions. Yeah, and I think people are working in fear. There's a practice that's been consolidated by Brene, my good friend Brene. It's called above and below the line practice. We'll share the resources and who she attributes this practice to. But when we are in fear, and fear is, as she puts it, fear is driving, we are below the line. And we will often inhabit one of three roles. The saviour. So in the scenario that I gave, I'm gonna go around and make sure that everybody's obs are okay, and if they're not okay, I'm gonna have a conversation with the nurse because if I don't do it, it won't happen. They're the persecutor or the villain, so they're the one going, Beverly, come here. How did you not know that a high heart rate and a low blood pressure? It was something to actually report. How did you not know that? Did you not go to nursing school like what the hell? Or they'll be the victim. Every time I'm on the shift, I'm on the shift with a pack of nurses who don't have a clue what they're doing, and I'm sick of it. It always happens to me. Is that resonating? It sounds very familiar. Yeah. Above the line behaviour is where fear is still present, but fear is not in control. And where again, there's that self-awareness piece, right? We're aware that fear is present. Oh my god, I've got a bunch of really new nurses. I'm not feeling very convinced of their capacity to actually join the dots. You have three different roles the coach, the challenger, and the creator. Yeah. So you might have do the pre-mortem. Hey, if you see something in the obs or in how the patient looks today and you're not sure what it means, I don't want you just to document it. I want you to come and talk to me or find another senior member of staff. So you're actually creating that pathway for them to take action and you're being really clear about what action you want them to take. Yeah, and the expectation. Yeah, that's right. You might also just check in with people before they go home. Hey, can I just check in? I know Mrs. Brown was not well yesterday. Can I just check in with you? How's she going? We're halfway through the shift. Oh, blood pressure's this and her heart rate's that at her last set of OBS two hours ago. You might go into Challenger. What did you think about when you noticed that? About those obs. What did we talk about at the start of the shift? What would be a good action for you to take right now? What would have been a better timeline to take that action?

SPEAKER_01 6:50

Yeah.

SPEAKER_00 6:51

Perhaps five hours before the red cold. Yeah, and I find the challenger and the coach can be similarly aligned because sometimes when you're in that coaching space, you're also actually challenging. But I think knowing where you sit, knowing if it is driving, it allows you to use better clinical judgment.

SPEAKER_01 7:15

Yeah.

SPEAKER_00 7:16

And it helps to be really clear with your team about what good clinical judgment looks like. So they can also do that too.

SPEAKER_02 7:26

Yeah. Yeah, completely. So we now work in environments that are complex and in challenging environments with lots of technology that does not yet make our life simpler. It does add some benefits, but it is certainly not simple. It is more complex. So we've got high cognitive loads. What do you reckon the interruption time is for most nurses when they're doing tasks? Do you mean how often? Like Yeah, how many seconds have they got between interruptions, do you think? Ah, seven seconds? Yeah. It feels like that. So think about you're drawing up medications. So on average, most tasks, we get 62 to 81 seconds. It's not even two minutes to give the antibiotics that take five minutes. None of our tasks do we have enough time for, which is a challenge. And one of the things I think about, and when I think about emotions, we and I'm somebody who really likes to think about myself as a very pragmatic person. And you and I both connected, uh, and early on we connected with the Elephants and Riders, which is a company, but has come from a philosophy around the rider is the pragmatic leader of where we want to go. It's the science thinker, which we like to think that all of our um our processes and decision making is very rational. But the elephant is the the emotions. An elephant's really big and an elephant just goes. And when we've got these emotions that we don't talk about and we don't name in the workplace, they drive a whole bunch of our behavior and make it a lot more complicated. So our emotions are more reactive. Uh, it's big, and once it goes, it kind of, you know, if I don't feel like getting up, well, it's really hard for my elephant to get up and get moving. Uh, but once it takes off, it's going to keep going and it's going to shuj everything out of the way. Um, and in our work concept, we in our thinking, we can only hold about seven pieces of information. And for some people, it's clearly five, and probably the most is nine pieces of information at any one time. There's very cool things you can do where you can test that for yourself. But in our clinical settings, we're having to hold lots of pieces of information at the same time, which makes this really, really difficult. And what are some things that you use around what let's start with, what impact do you see that emotions are having in the clinical space, in that work space, um, that we're not addressing very well?

SPEAKER_00 10:50

I think uh emotions, whether they be fear or something else, are undermining attention. They're undermining uh what people learn and particularly what they remember. The more uh emotional load we're carrying, the harder it is to remember things. I think emotions impact decisions, and often when there's high emotional load or big emotions, we are making decisions that are using less critical thinking and are more emotionally based. And we're not because we're trying to hide like I'm not you know, it's not about emotion, and we're not looking at it, and we're not welcoming it into the conversation, we're not aware of what it's doing. No, in the moment.

SPEAKER_02 11:44

So I think cognitive bias is a huge problem then. So when we're stressed, you know, and we well, I'm very pragmatic, and well, I don't have a any cognitive bias. Well, we know that we do, you know. If you do the the tests about what do you see as a pilot, more people will pick one gender over another or a particular height or a whole bunch of things that don't really make any sense, but that's our cognitive bias. When we're more emotionally heightened, those cognitive biases are much bigger. Yeah, way bigger. So um Daniel Kahneman, who is a fascinating, fascinating person, has written a couple of books, but one of them is around noise. And he describes that when judges make decisions, a very large amount of those decisions, and they're very pragmatic about what the criteria are for sentencing, but actually the sentences change more depending on whether their football team won on the weekend or not, which is amazing, right? It's Monday morning, the football team finished on the weekends, but that has an impact on their decision making. On imagine what happens in healthcare. I you know, our ability to have those conversations is just amazing.

SPEAKER_00 13:09

But I think that that research would have been very unpopular. I completely the research that says we are emotional first, cognitive second, is deeply uncomfortable for people in health. So one of the things I I just want to go back to your question. I think one of the things that it I see is most detrimental, driven by emotions, is relationships and whether they form, how they form, the quality of the relationship, are they sustainable? Will it last one of the people being promoted above the other person? The maturity that people display in relationships, how they show up in those relationships. One of the things I miss most about clinically nursing, and I think we've talked about this before, is the teamwork. And I always worked in ED mostly. So there was a really strong culture of teamwork. But you can imagine if emotions are running the show, what is happening to the relationships that in critical situations actually have to function and work and be really highly effective relationships. You said at the start, when that pager goes off, I can't even tell you my name, let alone where do I have to go. I don't know where that is. Have I been there before? Who am I? What day is it? When you think about what's happening in those really emergency situations, what have you seen play out in terms of emotions?

SPEAKER_02 14:48

So for me, the most problematic is probably the less dramatic. And perhaps that's because I don't like people being dramatic with their emotions, but I'm probably less traumatized maybe than other people. I see the most problem occurring when people shut down. So I see the most problem is people don't speak up, they don't say there's something wrong and I don't know what it is, or I know that you saw the patient 20 minutes ago, but it's not fixed, and I need you to do something even though you're busy doing other things. I think those things are really problematic, and you're right, that's about relationship. It's also emotions, it's fear for a whole bunch of reasons. That's a really big problem, and we see it more often now. One of our challenges that we need to think about is the cohorts that we've got working have changed in the last five years, in the last 10 years. And one of the things that we need to understand better and look at how do we incorporate this better in Australian healthcare? The things that are needed in critical thinking include truth-seeking, open-mindedness, being able to be analytic with looking at data, being systematic, having some self-confidence, being inquisitive, and having some cognitive maturity. If you score high in inquisitiveness, truth seeking, and open-mindedness, you are less likely to have problems with clinical judgment and your reasoning because you're looking for answers. You recognize that there's going to be multiple ways of answering. Those three things in particular are not valued in all cultures. No. And there's really good research to demonstrate that in many countries it is not okay to be open-minded, and you certainly shouldn't be truth-seeking. If somebody tells you that you should do it, then you should go do it. If you're in a country where it's a doctor's order, there are many countries still where that order is whatever is said is they rank much higher, you shouldn't question that. In Australia, that's not how we think. We think this is that there should be much more collaboration. But if you've grown up in that culture and are coming to Australia and having to learn this new way of doing things, and that is a very difficult thing to do. And it's not at all that people are stupid, but they've actually been taught that this is not a strength to have. This is not a thing that you fix this next week by saying, We want you to tell us when there's a problem. You are going to have to say it over and over, and you need to show them that when they speak up about something, that it is valued, regardless of what they've spoken up about. And often that's where we miss the mark because we don't recognize the effort that they've gone to tell us something that we don't really understand why they've why'd you tell me that? Like I don't care. We need to be really careful in those moments because in those moments they're learning whether they should speak up or not. We need to do everything we can to foster that because it is going to take a long time, like six to twelve months, maybe two years, for people to be able to relearn these patterns that are so different to what they've done for the last 30 to 50 years. That is a big part of our workforce now that we need to really unpack how do we do that and value it. And it there isn't a quick fix for that, which people want.

SPEAKER_00 18:51

Part of that goes back to communication. It's not just cultural, it can be family of origin.

SPEAKER_02 18:58

There's certainly national elements. Cultural, we all have a different story. It doesn't matter what our skin looks like or which country we came from, our story is very different completely. There's many families where you don't question.

SPEAKER_00 19:13

Something I'm continuing to explore is that idea of adult development. In in health and many other industries at the moment, people are given development opportunities when they reach a certain level in the organization. There's a huge opportunity missed in the concept of actually cultivating and developing people as adults from the moment they come through the door at any point in their career. It is how do I run this team where I permit and give to ask questions? How do I have this conversation? This is actually part of our team culture. Am I going to, you know, touch on this every week in our team meeting or every fortnight or every month? What else do I need to talk about that's going to change and help us to discuss acceptable behavioral norms in this organization? Um, I think part of what I like about the above and below the line practice and where this is leading is as a leader, asking yourself this question, what am I building? And what do I need to do to build that? What are the steps I need to put in place? And I think there's workplace and team foundations that are not in place. It makes it a lot harder. People are not aligned with Renee Thompson's work, people are not setting clear expectations for behaviors. Um, and often people are blindsided or shocked when they're given feedback that actually I heard your tone when you were talking to the new grad yesterday, and I've got to say it concerned me. What was the situation? Helped me understand where you were coming from. Now, the tone, if we go right back to emotions, the tone may not have been about the new grad at all. It might have been whatever the new grad did was the 50th thing today that's really pissed me off, and I just can't take anymore. And that person that to me is a lack of self-awareness about what I'm feeling and where I'm at, and what other pressures I'm under, and what emotions that's driving in me.

SPEAKER_02 23:05

Thing we can do to improve that is to absolutely recognize ourselves, but recognize when we need to actually just take a breath or whatever it is that we need to do. Yeah, recognize that actually, yes, my heart rate's gone up. Yes, my teeth are clenched, whatever it is that is our thing. Recognize when that's happening and take a moment to just step out. Glass of cold water, whatever you need to do, but take a minute to come back, recenter, recognize there's probably more to unpack here so that I can go back in and ask curious questions, which are really difficult to do when your emotions are at a really high level.

SPEAKER_00 23:53

Yeah. You asked me a question about how is this impacting? What I see is leaders who are short tempered, who want their team just to harden up, are just wanting people to be able to do their job. And these are not bad people, right? They're doing the best they can. What I hear is actually I'm under so much pressure, I can't take anymore. And if people are not doing their jobs, and if people are too emotional, and if people are taking leave because they had a difficult day yesterday, I can't cope with that because I'm up to here already with all the other stuff I'm doing. Yeah. Exactly what you said. They're not able to take a metaphorical or real breath in the moment. They're not recognizing the impact of what being up to here does to their behavior. They are just loosing off to their staff or responding in a way that is not supportive, empathetic, compassionate, or even boundried, right? Some people they're moving right into that persecutor role. For some people, they're moving into the savior role, and they're actually taking over, so they're taking on more load, and they're not teaching their team actually, here's what you need to do in this situation, so you can do it next time. And so then they're in like this cycle that they can't get out of because they don't know how to do it differently, because they've got such a huge cognitive and emotional load they can't think clearly, and make a clinical decision, which is I want to build this kind of team, they can't get there because they just don't have the space to do it.

SPEAKER_02 25:48

It might be useful for us to share some tips on how people can actually improve clinical judgment because I hear this being asked that we need training around clinical judgment because our team are not making good decisions, they're not escalating when they need to, and there's lots of reactive work happening around we need to teach people to think. We need to be really careful, it isn't about teaching them to think, it's about giving them the space to firstly learn what it is that we want them to do in a way that is beneficial, so safe. So simulation's a really useful way of doing that. You don't have to use simulation. The other thing that I think is super useful is actually supporting reflective practice. And we've talked previously about the challenges that we can have in reflective practice, and that most of us didn't learn this very well. But stepping in with people and saying, Today was a rough day. I really want you to take a minute before tomorrow shift and just make three or four lines and think about what would it have looked like if you'd done something different, or what do you think the trigger was for this to happen today? Really simple. It only needs to be a couple of sentences. Don't set people big homework, but just set them up to do the reflecting. We miss that really big opportunity. People do so much of their learning when we're not with them. We spend all of this time as educators going, oh, I've got all my people in front of me, they're gonna learn stuff. They don't learn when they're sitting in front of us, they learn when they're having their shower later, or they've gone for a swim, or they're sitting on the toilet, which is best not to think about, but that's where they're learning because they're thinking over it. I don't know image. We can set that up when you think about this later, because you will. I want you to answer these two questions, or I want you to think about what would this look like. Really simple, but set it up so that it's planned, and then you've got twice the time that you had that you were in front of them, and then come back to it. So value it and show that you value that practice by thinking about it, and then you can actually explore the conversation much more usefully.

SPEAKER_00 28:06

It's mind-boggling to me, as we've said before, that reflective clinical supervision, however you want to frame it, reflective practice is not a part of nursing. It's done informally in some work areas. There's support in the research for its benefits, but it's seen as an expensive thing. And I think sometimes it falls into the same category that coaching does. I have to do it this way, I have to do it for an hour, and I don't have time for that, so I'm just not gonna do it. When actually both of those things, as you've rightly said, can be quickly and easily set up.

unknown 28:48

Yeah.

SPEAKER_00 28:48

When you're starting something new, you've got to teach them how to respond. With coaching and reflective practice, here's what a response looks like. I don't need you to go into the nitty-gritty, I need you to answer the question for yourself. What for you was the turning point or the trigger in how today went or in what you experienced today at work. We've also talked about making that a regular practice if you have designated education time or in services that actually one in service a month or one education time a month is dedicated to reflective practice as a group. And it's and you're gonna have to do some work on creating the psychological safety, and you might do run the first one and go, Well, that was crap because no one else spoke but me and the educator, give it time. Yeah, you're you're introducing something new, it requires a high level of trust, but you will get there if you keep doing the same thing and you respond appropriately every time, and people feel will and recognize people's bad experiences with it previously.

SPEAKER_02 29:58

It's like simulation, yeah. You will have to do it three or four times, recognize that and acknowledge it up front. Going, I know you when you did this previously, it sucked. What experiences have you had? This is what we're gonna do. It's beneficial because of these things.

SPEAKER_00 30:13

We're gonna give it a go for a while. You can have it as a standing agenda item in your team meeting if you don't have designated education time or it gets impacted by clinical requirements. And it doesn't have to take long, it can be 10-15 minutes, and you can you can pick a day from the last month. We're gonna spend 10 minutes just thinking about Tuesday the 23rd. Let's set some context. And I just want I'm gonna give you one question, and I just want you to write for five minutes about that question, and then we'll have a brief discussion with whatever people want to share. Love it. It's not hard, but I think people think it has to happen one way. There are lots of ways to do this, and remember, you're not gonna build trust by having a one-hour reflective practice session, you're gonna build trust by having 10 minutes once a month over the next six months and responding in the same way every time with curiosity and compassion. Can I do one more thing? One of the things that I found really important because I think as a as a leader, managing your reaction, your emotional reaction to situations is super important. And a little bit like the muscle memory we build when we do BLS over and over and over and over and over and over again. That helps us when the pager goes off. Yes. Having a sequence that you do when you recognize you're getting irritated or annoyed or frustrated, or you're having a reaction to an event that may or may not be appropriate, but you want to have time to check in. I want to share something that I've been practicing for about five years now and it's completely shifted. I still react, but frequently I often am able to also go, hang on, that was a reaction. Can you just give me a sec? So what I actually do, because I don't remember scripts particularly well, and if there's too many words, I think it's my amount is maybe five things. I have a routine of notice, ask. Hey, I noticed that you were really quiet in the room today, and I wanted to check in with you because I know last night was really heavy and that maybe you didn't reflect with anybody. So what's on your mind today? I love that. The practice is actually the noticing I need to notice and the asking a good question. But the more you do it, I still ask a question, then go, no, hang on, that's the wrong question. Give me a sec. Okay, it's actually this question. This is a better question.

unknown 32:49

Yeah.

SPEAKER_00 32:49

People respond, yeah.

SPEAKER_02 32:51

Right? Yeah, yeah, you're a human, nobody needs you to be perfect all the time. No. If you're interested, you're a long way ahead.

SPEAKER_00 32:57

Yeah. What I want to feel this year is proud. I want to feel proud of how I show up. I want to feel proud of how I manage myself. I'm not going to get it right all the time, but that's my guiding star. I had lots of conversations this year because of setting myself up like that, and because of the notice and ask, where I've actually walked out feeling proud. Have I solved the problem 100%? Don't know how's the other person feeling? Well, I think they're probably feeling hurt, otherwise, I wouldn't feel proud, very proud of how I showed up. So it's been really useful just to set myself up a little bit and have that guide. I would recommend is just think about I've given you two questions now. What are you building in your team? And what do you want to feel this year?

SPEAKER_02 33:51

I think they're great questions.

SPEAKER_00 33:53

Let's end there.

SPEAKER_02 33:54

Okay. Thanks for listening. You can check out the show notes and find lots of further resources at bettereveryshift.com.au or via the link below. If you enjoyed today's episode or would love further information, we would love you to subscribe. We look forward to seeing BetterEvery Shift.