Critical Thinking in Healthcare: The Patient Discharge Process

Healthcare today is complex and fast paced. The speed of change, the swift growth of technology, increased patient acuity, and the demand for increased safety and quality of care have all contributed to increased complexities and the subsequent demand for higher-order thinking skills in the modern healthcare setting. Critical thinking skills are therefore more essential than ever at all levels and throughout all roles in today's health care environment. Over the next few months I intend to write several blogs on how Critical Thinking training may help healthcare professionals better cope with the challenges they face.  Today, I want to focus on nurses.

Nursing educators have recognized Critical Thinking as an essential skill for over half a century and more recently professional and regulatory bodies have required that critical thinking training be included in all nursing education programs. This is because better problem solving and decision-making skills are dependent on critical thinking proficiency. Being able to think reflectively and to consider alternatives, and not simply accept directions and perform tasks without deep understanding and consideration, enables nurses to better meet the needs of their patients resulting in better quality of care and a better patient experience.

In very general terms, these are the reasons why Critical Thinking is recognized as such an important skill for people working in healthcare, in particular, nursing.  But Critical Thinking is also beneficial for specific tasks within a nurse’s vast set of responsibilities. Let's consider for a moment the patient discharge process:

The discharge process ensures patients who are preparing to leave the hospital are provided all of the information they need concerning their care once they get home. Many hospitals struggle with this. The problem is that a good discharge protocol doesn’t merely ensure the patient has all of the relevant information at hand; it needs to ensure that the patient has understood the information.

The discharge process has many moving parts. For example, a discharge planner (usually an RN) must be able to communicate effectively with team members, sometimes be the patient’s liaison with their insurance company, home health provider, or physician, and perhaps most critically, effectively communicate discharge instructions to the patient. This is critical because when a patient understands and complies with her discharge instructions she will be more likely to have a good clinical outcome and less likely to be unnecessarily readmitted back into the hospital.

While I think it is clear that good communication is fundamental to a successful and effective discharge procedure, many organizations are attempting to address gaps in their discharge procedures by further structuring the process. For example St. Joseph’s Healthcare Hamilton recently launched a comprehensive discharge plan designed to ensure patients understood their post discharge instructions (you can find it here in the Ontario Hospital Association's Idea Book.)  St. Joe's recognized the need for clarity in communication and developed a discharge form that lists pertinent discussion points necessary for a patient’s discharge and requires staff and patients to sign off that both the instructions were given and understood.

Similarly AHRQ, who is committed to advancing excellence in healthcare in the US, has released a free toolkit RED (Re-Engineered Discharge) designed to reduce readmissions by integrating better communication among clinicians and patients.

These and other approaches tend to highlight documenting solutions to scenarios and implementing checklists. These are useful, and are steps in the right direction, but what is missing is the investment in skills development to address gaps in a more fundamental and far-reaching way.

Critical Thinking training improves communication, problem solving and decision making, all of which are integral to the discharge process. As we discussed in our last blog entry, at the heart of Critical Thinking is the ability to reconstruct and evaluate arguments. We use our Critical Thinking skills to determine if arguments are cogent and to see if the argument's premises provide good reasons for accepting the conclusion. But Critical Thinking training also improves our ability to construct cogent arguments and articulate these effectively.

When we are trying to convince a patient that the medication schedule and rehab requirements are important once they leave the hospital, and that they should not return to work for 7 days and that the side effects of their surgery might cause symptoms A, B and C (and to not be concerned) but also might cause D and E (and to get in touch with a healthcare professional immediately if they do appear), we are constructing an argument and we are using this argument to influence the patient to adhere to these instructions. We may also be evaluating arguments offered by a patient who does not feel she can comply with the instructions, or who is unsure of something not considered on our discharge form.  All the time we are unpacking assumptions, evaluating premises and conclusions and negotiating compliance.

This is the process of effective communication from a Critical Thinking perspective and it will ensure the patient has understood her discharge instructions and will also help ensure she complies with them.

I started off by discussing in general terms the value of Critical Thinking skills in healthcare and ended by discussing the role of engaging the patient to ensure the transfer of information during the discharge process. It is worth noting that there are many other aspects of discharge planning that would benefit from critical thinking skills, though not discussed here.  The challenge as I see it is that Critical Thinking skills take time to develop and a nurse’s exposure to formal Critical Thinking training will likely have been short and introductory, and therefore it is unlikely that nursing students have leveraged this training to the fullest intended benefit.  Perhaps what healthcare needs is a more integrated and comprehensive professional development solution to ensure all healthcare professionals are continually improving their critical thinking skills.

If you found this interesting please stay tuned for more posts discussing the value of Critical Thinking education for healthcare professionals.