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T.H.I.N.K.

Modes

Total Recall (T)

Total recall means remembering facts or remembering where and how to find them

when they are needed. Nursing facts come from many sources the content taught in

classes, information in books, those things told to the nurse by a patient or significant other,

patient data collected through the senses, instruments, and so forth. Some examples of facts

include the date the Crimean War ended; normal values for hematocrit; a specific patients

hematocrit; who Florence Nightingale was; the second disassociation constant of malefic

acid; a patients statement, Im so tired all the time; the correct way to don sterile gloves;

and so forth. These facts are stored in memory, for either short or long periods of time. Total

recall is comparable to having the ingredients and equipment for a cake. Having the

ingredients is the first step; there is no cake yet because nothing has been done with the

ingredients, but they are a necessary prerequisite.

Total recall also is the ability to access knowledge, with knowledge being something

learned and kept in the mind. Each person has a variety of knowledge clusters in his or her

mind. Some clusters are very large these represent things about-which a person is very

knowledgeable. Other clusters are small. Beginners in nursing have a small cluster of

nursing knowledge that rapidly expands during the school years.

How total ones recall is depends on memory. Memory is a complex process. Some

people can remember many seemingly isolated facts effortlessly; others struggle. If you are a

struggler, dont despair. There are ways to help you remember. Putting facts into patterns is

one way. The T.H.I.N.K. mnemonic is an example-a pattern to help you remember the five

modes of thinking. Often, however, patterns are not quite so obvious. You have to make or

find the patterns in your brain and use them. Look at this set of numbers: 5555068527. Now,
look at the same set written this way: (555) 506-8527. As you can see, it is a telephone

number. The numbers are easier to remember because there is a familiar pattern to them.

Look at another list. See if you can remember this after reading it; car, train, fork, orange,

plate, apple, spoon, airplane, cup, banana, bicycle, watermelon. Now look at the same list

arranged in a pattern. There are four items in each of three categories.

car fork orange

train plate apple

airplane spoon banana

bicycle cup watermelon

the way people receive information also affects their ability to recognize patterns.

Test this out with a friend. Create a list of items that you know can be categorized, mix up

the items, and read them to a friend to see if he or she can remember them. Then show the

friend the written words in the order that you originally read them and see if he or she can

remember them. Which way was easier? Could the friend recognize the patterns more

quickly when hearing or when seeing? Have the friend do the same for you. Learn how your

mind processes information to get it into your memory. The experience will also give you

some clues on how to study and learn the mountains of facts you need to remember in

nursing school.

Another process for remembering is the association of a fact with some experience.

Most forty-ish people can remember exactly what they were doing the day President John

Kennedy was shot. Other associations may be less dramatic. You may remember something

you heard in a lecture because the teacher supported the fact with a funny story. You may

remember something else because you had to perform some action to or with it. For

example, if someone told you how to use jumper cables to start your car, you might
remember it. But you would remember it better if you actually got stuck and had to jump

start your car with cables?

Habits (H)

Habits are thinking approaches that are repeated so often they become second nature.

They result in accepted ways of doing things that work, save time, or are necessary. People

often describe things that they do habitually as things I do with out thinking. Its not that

habit actions are done without thought; its just that the thought processes have become so

ingrained that they seem to be, or actually may be, subconscious.

Habits allow one to do things without having to figure out a new method each time.

Riding a bicycle and driving a car are habits for people who do them on a regular basis.

Have you ever driven several miles and then realized you could not remember what you saw

or what streets you passed? Hopefully, you did not cause any accidents as you got from point

A to point B with no recollection of the trip. You could do this mindless driving because

you had already mastered the basic mechanics of driving and could do it without conscious

effort. (This is not a recommended way of driving a car, but it does demonstrate how habits

work.)

Cardiopulmonary resuscitation (CPR) is a very useful habit in nursing. When

someone is lying at your feet looking dead, there is no time to come up with a creative way

to bring him or her back to life. A quick solution is needed here. Nursing has many other

procedures comparable to CPR the proper way to give an injection, take a temperature,

inset a catheter, and many more such activities. When these actions are first learned, they

obviously are not yet habits, but as they are used repeatedly, they become second nature;

they become habits. You will appreciate how many of these habits will be formed by the time

you graduate.
Sometimes habits can be traced back to thinking sources easily. CPR, for example, if

practiced repeatedly, can become second nature; however, most nurses can remember their

first experice with that process and explain how it became a habit with time.

There are other habits whose thinking roots are not as obvious. These are intuitive

processes. Intuition is often described as a gut level reaction. Polanyi (1964) described a

similar phenomenon, which he called tacit knowing, in which the steps of the discovery

cannot be identified. Nurses use expressions such as, I just had a feeling something was

wrong, to describe their thinking that led to their feeling in certain situations. Usually

these situations are ones with which the nurse is familiar. It is very difficult to put those

thought processes into words because they seem to be instantaneous or though-less.

Intuition, which used to be seen as unscientific and invalid, has recently received more

attention in nursing. During their research. Benner, Tanner and Chesla (1996) have asked

nurses to describe their thoughts, including those that are intuitive. They found that there are

specific thought processes at work in intuitive situations and have boldly concluded that

reason requires intuition.

Inquiry (I)

Inquiry means examining issues in depth and questioning those that may seem

immediately obvious. If you did this level of questioning in a social situation, you would be

called really pushy. It involves digging and questioning everything especially ones own

assumptions in a given situation. It means not taking anything at face value, looking for the

less-evident factors, doubting all first impressions, and checking out everything, no matter

how seemingly insignificant.

Inquiry is the primary kind of thinking used to reach conclusions. Conclusions can be

reached without using inquiry, but conclusions are better (more accurate) if inquiry is used.
For example, one day, while sitting at her desk, Sue glanced up at the window and saw that it

was wet. Her immediate conclusion was, Its raining and I wont be able to go to the beach

when Im finished studying. On a closer look, Sue saw what there was no water on the

grass, the sun was shining, there were no clouds, and there was a ladder visible on the side of

the window. Sue really wanted it to be sunny because she wanted to go to the beach after she

finished her studying, so she stopped for a moment to make sure her mind was not playing

tricks. She considered that a lawn sprinkler might be spraying the window. She stood up to

look at a different angle (inquire), and there was a window washer on the ladder with a

squeegee. Relieved, Sue came to the most accurate conclusion the windows were being

washed.

In this story, Sue used inquiry when she did the following:

saw something (received information)

came to an immediate conclusion

recognized some gaps in her knowledge

collected additional information to rule in our rule out the first idea (immediate

conclusion)

compared new information to what was already known about situations like this

by using past experience

questioned any biases

considered one or more alternative conclusions, and

validated the original or the alternative conclusion with more information.

This process of collecting and analyzing information to confirm or to make additional

conclusions beyond the obvious ones is the essence of inquiry. Conclusion-making will be
discussed in much greater detail in later chapters, but, for this discussion of inquiry, it is

important to consider the pitfalls to making accurate conclusions. It is very easy to jump to a

conclusion based on insufficient information or on ones own assumptions. It is also

tempting to jump to conclusion without inquiry because it is a faster process. Inquiry,

especially when it is first being practiced, can be a slow, cumbersome, even a scary process.

Take the consideration of missing information, for example. A beginning nurse might need to

find a book and look up facts to know that more information is needed. The ability to

recognize what is missing and to fill in those gaps is essential to counteract premature

conclusion-making and well worth the time.

The ability to self-critique also is essential to inquiry-based conclusions. Everyone

has assumptions about all kinds of things. These assumptions may be so ingrained that we

are unaware of them. However, most of the time, if we stop and question ourselves, we can

see our assumptions. The stopping and questioning must be cultivated; it doesnt just happen.

Interactions with other students and nurses, especially those with backgrounds different from

ones own, will help in recognizing ones assumptions.

Another questioning part of inquiry is considering consequences, or asking what if

questions. What will happen if . (I do this) (I make this conclusion) (the patient thinks

this)? Projecting future actions or reactions helps verify and justify the conclusions one

makes.

In this window-washer station, the final conclusion is probably quite accurate and

fairly simple. Obviously, not all situations in nursing are quite this simple. Most situations in

nursing practice require inquiry. Sometimes a single validated conclusion emerges; at other

times, several conclusions may seem equally valid. In those cases, the nurse needs to repeat

the inquiry until the one conclusion that is most accurate is found. This sounds very time
consuming, and sometimes it is, but in most cases the process occurs in microseconds,

especially for experienced nurses. Many textbooks refer to this process when they describe

diagnostic reasoning. In chapters 5 to 8 you will see why this thinking is used for diagnostic

reasoning.

Examine this example of a fairly simple nursing situation:

Its 3 AM in the hospital and Ms. Avon, the nurse, sees a patients overhead room

light on.

She walks into the room and says,Hi, Mr. Trent, I noticed your light on. How are

you doing?

The patient smiles and says, Im fine.

The nurse observes that there are wads of used tissues on the floor; the sheets are all

twisted; Mr. Trents eyes are puffy and red.

Inquiry is called for here. The nurse must make a preliminary conclusion about

something that is not readily apparent. The patient is smiling and saying nothing is wrong.

Would Ms. Avon accept his response and conclude that he is fine? Not if she were using

Inquiry. She would have to put several pieces of information together to make some sense

out of the situation. She would recognize that there may be no simple answer, but several

possible conclusions.

Using inquiry allows Ms. Avon to consider at least the following four conclusions

the patients is fine, is normally awake at this hour, and may have been rubbing his

eyes because of his allergies.

The patient is fine but cant sleep because he napped all day because of boredom.

His eyes are always red and puffy.

The patient is not fine but doesnt want to talk about it our bother anyone.
The patient is not fine but doesnt know how to ask for help.

To say with any degree of certainty that one of these four conclusions is better than

the others, the nurse needs to validate her conclusion, to put together as much information as

possible, and to ask Mr. Trent directly if he agrees with the final conclusion. (She might say,

Mr. Trent, you aid you were fine, but it seems to me you might be upset.) to get the

necessary information. She would need to analyze the information by looking for patterns

and determining what was significant. Determining significance is dependent upon the

nurses ability to think about how the information about the patient compares with the

nursing knowledge she has learned. For example, she compares the patients red, puffy eyes

with her knowledge about what normal eyes look like. This comparison leads her to

conclude that red, puffy eyes are significant (relevant) information.

Note that the knowledge (Total Recall thinking) is not enough. A nice, neat package

or answer to many real world situations cannot always be found in a book. Books help

nurses see patterns by providing factual information, such as typical behavior patterns or the

appearance of eyes, but the nurse has to put that information together with the information

found in each unique situation. Books describe the usual ways to interpret information and

the usual rules, but not everyone or every situation fits into these usual patterns (norms). For

example, most people are asleep at 3 AM, but not all; most peoples eyes are not red and

puffy, but some peoples eyes are. You have to use inquiry to collect key information and put

the pieces together in meaningful patterns. No books can do this for you. Only your thinking

can do the job!

Based on the descriptions of inquiry thus far, how would you judge your present

ability to use inquiry on a scale of 0 to 10, with 10 being outstanding? Be sure to write this

number down so you can compare it with your inquiry ability at the end of the book.
New Ideas and Creativity (N)

New ideas and creativity comprise a thinking mode that is very special to you. This

individualized thinking goes beyond the usual to reconfigure the norm. Like inquiry, this

mode allows you to go beyond textbook ideas. Creative thinking is at the opposite end of the

spectrum from the HABIT mode. Instead of saying, This is new way. Creative thinking is

not for the faint-hearted; one must be willing to risk looking foolish occasionally and not

fitting the mold. A creative thinker appreciates mistakes for their learning value. (This can be

uncomfortable if you have been told all of your life to avoid mistakes.) chances are, if you

are like most people, you have not been encouraged to be creative to the point of being

different from the rest of the crowd, however, everybody is creative under certain

circumstances.

New ideas and creativity are very important in nursing because they are at the root of

customized or individualized care. Many things nurses learn have to be mixed, matched, and

reworked to fit each unique patient situation. Nursing has many standard approaches to care

that save time and generally work well, but they do not work the same way for everyone.

Take, for example, Ethel (not her real name), who lived in a nursing home and spent her days

wheeling her wheelchair up and down and up and down the same hall. She spoke to no one

despite repeated verbal prompting by very caring nurses who knew the importance of

communication.

When thinking of communication, most people think of talking to somebody; that is

the standard way to encourage people to communicate. So that is what most nurses did,

except for Maria (her real name). One day Maria knelt down next to Ethels wheelchair, gave

her a big hug, looked Ethel straight in the eye and, with a big smile, said, Lets sing. Guess
what happened? Ethel sang. Not only could she sing, but she had the voice of an Irish folk

singer.

Now what is the thinking lesson in this story? Other nurses knew recipes (standards)

for therapeutic communication that they learned in the textbooks. They used them with the

best intentions. Standard verbal approaches to therapeutic communication work with most

patients. Maria, however, expanded the definition of communication to include singing and

touching, thus creating and individualized approach for Ethel that was not in any textbook.

From that point on, Ethel always responded to Maria by smiling. She even gave one-

or two-word responses to Marias questions and, on occasion, sang with the other nurses.

One small, creative approach that individualizes care often has a way of mushrooming into

bigger and better things.

Knowing How You Think (K)

Knowing how you think, the last, but not the least, of the T.H.I.N.K. modes, means

thinking about ones thinking. Thinking about thinking is called met cognition, a word

composed of the prefix, meta, which means among or in the midst of, and cognition,

which means the process of knowing. If you get in the midst of your process of knowing,

you will get to know how you think.

Display 1-2 provides a vocabulary that is useful in describing how one thinks. As you

think about your thinking, you may use these words as cues. Ask yourself, for example, what

assumptions you tend to make, what your point of view and biases are, and how you

elaborate on ideas. Think about what evidence means to you and how you deal with

contradictions. Continue in this way until you have considered all the words on the list.

Knowing how you think is not as simple as it may sound. Most of us just think; we

do not spend a great amount of time pondering how we think. Nursing, however, requires
that we be critical thinkers. Part of critical thinking is the constant striving to makes ones

thinking better or to know how you think. Making ones thinking better is impossible if

one doesnt know where one is to begin with. One of the ways to identify where you are now

and to begin exploring how you think is with the use of self-reflection.

Schon (1983), a well-known educator, wrote what is now a classic work for

practitioners who want to be more reflective. He advocated a reflection-in-action approach

for professionals, especially those in fields where problems and solutions are not easily

found in texbooks. Certainly, nursing fits into what Schon calls the swampu lowlands, or

areas of practice where situations are messy and often not conductive to clear-cut, technical

solutions offered by textbooks. The best nurses use this reflective process (knowing how you

think) to constantly adapt their thinking to the ever-changing contexts of patient needs and

the health care arena.

So, what is a good way to identify your skills in reflection and begin to nurture them?

It is often easier to describe something abstract (such as knowing how you think) by linking

it to a specific situation, rather than trying to talk about it in general terms (Brookfield,

1987). Reflective nurses take time to think over specific situations while they are in those

situatiosn and afterward. They mull things over in their minds and try to improve how they

think and what they do by focusing on what they thought, felt, and did in that particular

situation. They ask themselves questions such as these: Why did I feel comfortable (or

uncomfortable) in that situation? How could I have missed that? What did I assume and

why? What would have helped? Is the patients thinking similar to mine? There are

many such questions that change from situation to situation. As more and more situations are

reflected upon, the nurse grows in the Knowing How You Think mode.
The following is an example of a nurse who exhibits the Knowing How You Think

mode as he describes his thinking style.

I know I have a tendency to jump to conclusions because I need to keep things neat.

Not being able to figure out whats going on right away makes me anxious. When Im

anxious I tend to focus on the negative part of things, like not having enough time to do

everything, and that adds to my premature conclusion-making. What i do now, because I

know that, is to think aloud more when Im in patient situations. I let them know what Im

thinking so they can validate or correct my conclusions. I also say to myself, do I have

evidence to support my inference here? I also dont have a very good memory for specific

things like lab values, so I have trouble determining the relevance of those things. Therefore,

I always keep reference books handy so I can look things up easily. I used to be afraid to say

I dont know, thinking that I should know everything a patient asks me, but now I take

those uncertain opportunities and turn them into learning situations for the patient and me. I

say things like, Well, lets see if we can figure this out together. I also know that I have

biases against people who do not take an active role in their care. Thinking out loud with all

patients helps me overcome that bias because it puts partnership into the forefront.

For more example soft this kind of expect nursing thinking you may want to check

out a book by Benner, Tanner, and Chesla (1996) called Expertise in Nursing Practice:

Caring, Clinical Judgment, and Ethics. In this book the authors present many direct

quotations from nurses as they describe their thinking in the real-life, swampy lowlands of

nursing.