examples of critical thinking in icu

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Ann Am Thorac Soc

Critical Thinking in Critical Care: Five Strategies to Improve Teaching and Learning in the Intensive Care Unit

Margaret m. hayes.

1 Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

2 Shapiro Institute for Education and Research at Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; and

Souvik Chatterjee

3 Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Massachusetts

Richard M. Schwartzstein

Associated data.

Critical thinking, the capacity to be deliberate about thinking, is increasingly the focus of undergraduate medical education, but is not commonly addressed in graduate medical education. Without critical thinking, physicians, and particularly residents, are prone to cognitive errors, which can lead to diagnostic errors, especially in a high-stakes environment such as the intensive care unit. Although challenging, critical thinking skills can be taught. At this time, there is a paucity of data to support an educational gold standard for teaching critical thinking, but we believe that five strategies, routed in cognitive theory and our personal teaching experiences, provide an effective framework to teach critical thinking in the intensive care unit. The five strategies are: make the thinking process explicit by helping learners understand that the brain uses two cognitive processes: type 1, an intuitive pattern-recognizing process, and type 2, an analytic process; discuss cognitive biases, such as premature closure, and teach residents to minimize biases by expressing uncertainty and keeping differentials broad; model and teach inductive reasoning by utilizing concept and mechanism maps and explicitly teach how this reasoning differs from the more commonly used hypothetico-deductive reasoning; use questions to stimulate critical thinking: “how” or “why” questions can be used to coach trainees and to uncover their thought processes; and assess and provide feedback on learner’s critical thinking. We believe these five strategies provide practical approaches for teaching critical thinking in the intensive care unit.

Critical thinking, the capacity to be deliberate about thinking and actively assess and regulate one’s cognition ( 1 – 4 ), is an essential skill for all physicians. Absent critical thinking, one typically relies on heuristics, a quick method or shortcut for problem solving, and can fall victim to cognitive biases ( 5 ). Cognitive biases can lead to diagnostic errors, which result in increased patient morbidity and mortality ( 6 ).

Diagnostic errors are the number one cause of medical malpractice claims ( 7 ) and are thought to account for approximately 10% of in-hospital deaths ( 8 ). Many factors contribute to diagnostic errors, including cognitive problems and systems issues ( 9 ), but it has been shown that cognitive errors are an important source of diagnostic error in almost 75% of cases ( 10 ). In addition, a recent report from the Risk Management Foundation, the research arm of the malpractice insurer for the Harvard Medical School hospitals, labeled more than half of the malpractice cases they evaluated as “assessment failures,” which included “narrow diagnostic focus, failure to establish a differential diagnosis, [and] reliance on a chronic condition of previous diagnosis ( 11 ).” In light of these data and the Institute of Medicine’s 2015 recommendation to “enhance health care professional education and training in the diagnostic process ( 8 ),” we present this framework as a practical approach to teaching critical thinking skills in the intensive care unit (ICU).

The process of critical thinking can be taught ( 3 ); however, methods of instruction are challenging ( 12 ), and there is no consensus on the most effective teaching model ( 13 , 14 ). Explicit teaching about reasoning, metacognition, cognitive biases, and debiasing strategies may help avoid cognitive errors ( 3 , 15 , 16 ) and enhance critical thinking ( 17 ), but empirical evidence to inform best educational practices is lacking. Assessment of critical thinking is also difficult ( 18 ). However, because it is of paramount importance to providing high-quality, safe, and effective patient care, we believe critical thinking should be both explicitly taught and explicitly assessed ( 12 , 18 ).

Critical thinking is particularly important in the fast-paced, high-acuity environment of the ICU, where medical errors can lead to serious harm ( 19 ). Despite the paucity of data to support an educational gold standard in this field, we propose five strategies, based on educational principles, we have found effective in teaching critical thinking in the ICU ( Figure 1 ). These strategies are not dependent on one another and often overlap. Using the following case scenario as an example for discussion, we provide a detailed explanation, as well as practical tips on how to employ these strategies.

A 45-year-old man with a history of hypertension presents to the emergency department with fatigue, sore throat, low-grade fever, and mild shortness of breath. On arrival to the emergency department, his heart rate is 110 and his blood pressure is 90/50 mm Hg. He is given 2 L fluids, but his blood pressure continues to fall, and norepinephrine is started. Physical examination is normal with the exception of dry mucous membranes. Laboratory studies performed on blood samples obtained before administration of intravenous fluid show: white blood cell count, 6.0 K/uL; hematocrit, 35%; lactate, 0.8 mmol/L; blood urea nitrogen, 40 mg/dL; and creatinine, 1.1 mg/dL. A chest radiograph shows no infiltrates. He is admitted to the medical intensive care unit. Attending: What is your assessment of this patient? Resident: This is a 45-year-old male with a history of hypertension who was sent to us from the emergency department with sepsis. Attending: That is interesting. I am puzzled: What is the source of infection? And how do you account for the low hematocrit in an essentially healthy man whom you believe to be volume depleted? Resident: Well, maybe pneumonia will appear on the X-ray in the next 24 hours. With respect to the hematocrit...I’m not really sure.

Five strategies to teach critical thinking skills in a critical care environment.

Strategy 1: Make the “Thinking Process” Explicit

In the ICU, many attendings are satisfied with the trainee simply putting forth an assessment and plan. In the case presented here, the resident’s assessment that the patient has sepsis is likely based on the resident remembering a few facts about sepsis (i.e., hypotension is not responsive to fluids) and recognizing a pattern (history of possible infection + fever + hypotension = sepsis). With this information, we may determine that the learner is operating at the lowest level of Bloom’s taxonomy: remembering ( 20 ) ( Figure 2 ), in this case, she seems to be using reflexive or automatic thought. In a busy ICU, it is tempting for the attending to simply overlook the response and proceed with one’s own plan, but we should be expecting more. As indicated in the attending’s response, we should make the thinking process explicit and push the resident up Bloom’s taxonomy: to describe, explain, apply, analyze, evaluate, and ultimately create ( 20 ) ( Figure 2 ).

The revised Bloom’s taxonomy. This schematic, first created in 1956, depicts six levels of the cognitive domain. Remembering is the lowest level; creating is the highest level. Adapted from Anderson and Krathwol ( 20 ).

Faculty members should probe the thought process used to arrive at the assessment and encourage the resident to think about her thinking; that is, to engage in the process of metacognition. We recommend doing this in real time as the trainee is presenting the case by asking “how” and “why” questions (see strategy 4).

Attending: Why do you think he has sepsis? Resident: Well, he came in with infectious symptoms. Also, his blood pressure is quite low, and it only improved slightly with fluids in the emergency department. Attending: Okay, but how is blood pressure generated? How could you explain hypotension using other data in the case, such as the low hematocrit?

If the trainee is encouraged to think about her thinking, she may conclude that she was trying to force a “pattern” of sepsis, perhaps because she frequently sees patients with sepsis and because the emergency department framed the case in that way. It is possible that she does not have enough experience in the ICU or specific knowledge about sepsis to accurately assess this patient; in the actual case, a third-year resident with significant ICU experience ultimately admitted to defaulting to pattern recognition.

One way to push learners up Bloom’s taxonomy is to help them understand dual-process theory: the idea that the brain uses two thinking processes, type 1 and type 2 (alternately known as system 1 and system 2). Type 1 thinking is the more intuitive process of decision making; type 2 is an analytical process ( 17 , 21 , 22 ). Type 1 thinking is immediate and unconscious, and the hallmark is pattern recognition; type 2 is deliberate and effortful ( 17 ).

Critical thinkers understand and recognize the dual processes ( 21 ) and the fact that type I thinking is common in their daily lives. Furthermore, they acknowledge that type 1 reasoning, which is often automatic and unconscious, can be prone to error. There is a paucity of data linking cognitive errors to the particular type of thinking ( 14 ), but many of these studies are plagued by the fact that they do not test the atypical pattern. As a consequence, they do not truly test the hypothesis that type 2 reasoning will reduce error in more complex cases. It has been shown that combining type 1 and type 2 thinking improves diagnostic accuracy compared with just using one method versus another ( 23 ). We believe that helping learners understand how their minds work will help them recognize when they may be falling into pattern recognition and when this will be problematic (e.g., when there are discordant data, or one can only quickly think of one diagnosis). By expecting more from our learners, by compelling them to understand, analyze, and evaluate, we must provide constant feedback and coaching to help them develop, and we must ask the right questions (see strategy 4) to guide them.

Strategy 2: Discuss Cognitive Biases and De-Biasing Strategies

Cognitive biases are thought patterns that deviate from the typical way of decision making or judging ( 24 ). These occur commonly when we are under stress or time constrained when making decisions. At this time, there are more than 100 described cognitive biases, some of which are more common in medicine than others ( 25 ). We believe that the six outlined in Table 1 are particularly prevalent in the ICU.

Six common biases frequently used in the intensive care unit

The definitions of these biases are based on their application and use in clinical medicine. Table adapted from Croskerry ( 6 ), Croskerry ( 27 ), and Hogarth ( 37 ).

Although there are many proponents of teaching cognitive biases ( 6 ), there are no studies showing that teaching these to trainees improves their clinical decision making ( 14 ), again recognizing that research in this area has often not focused on the scenarios in which cognitive bias is likely to lead to error. Most cognitive biases are quiescent until the right scenario presents itself ( 26 ), which makes them difficult to study in the clinical context. Imagine an overworked, tired resident in a busy ICU or one who received an incomplete sign-out or felt pressure from the system to make a quick decision to move along patient care. These scenarios occur daily in the ICU; as a consequence, we believe that teaching residents how to recognize biases and giving them strategies to debias is important.

The resident in the clinical scenario outlined here is falling prey to many biases in her assessment that the patient has sepsis. First, it is likely that on her ICU rotation she has seen many patients with sepsis, and thus sepsis is a diagnosis that is easily available to her mind (availability bias). Next, she is falling victim to confirmation bias: The presence of hypotension supports a diagnosis of sepsis and is disproportionately appreciated by the trainee compared with a white blood cell count of 6,000, which does not easily fit with the diagnosis and is ignored. Next, she anchors and prematurely closes on the diagnosis of sepsis and does not look for other possible explanations of hypotension. The resident does not realize that she is subject to these biases; explicitly discussing them will help her understand her thinking process, enable her to recognize when she may be jumping to conclusions, and help her identify when she must switch to type 2 thinking.

Attending: Why do you think he has sepsis? Resident: Well, he came in with infectious symptoms. Also, his blood pressure is quite low, and it did not improve with fluids in the emergency department. This is similar to the other patient with sepsis. Attending: I can see why sepsis easily comes to your mind, as we have recently admitted three other patients with sepsis. These patients had similar features to this patient, so your mind is jumping to that conclusion, but if we stop and think together about what pieces of the case don’t fit with sepsis, we may come up with a different diagnosis. Resident: Well, the lack of leukocytosis doesn’t make sense. Attending: Yes! I agree, that is a bit odd. Let’s broaden our differential and not anchor on sepsis. What else could this be?

Cognitive forcing strategies ( 16 ), the process of making trainees aware of their cognitive biases and then developing strategies to overcome the bias, may help this resident. Studies show that debiasing can be taught to emergency medicine trainees ( 27 ), and we believe it can also be taught to critical care trainees, who experience a similar fast-paced and high-stakes learning environment. Proposed debiasing strategies include encouraging trainees to consider alternative diagnoses ( 3 , 6 , 27 , 28 ) and promoting broad differentials. In particular, they need to be able to rethink cases when confronted with information that is not consistent with the working diagnosis; for example, leukocytosis, as above. They should be allowed to communicate their level of uncertainty, and we should not think less of them if they do not have a single final answer with a targeted plan ( 29 ). When we do not discuss inconsistent information, we essentially give trainees permission to ignore it.

Attending: In addition to the white blood cell count not fitting, I’m also struggling with the hematocrit: How is it 35% in the setting of presumed decreased intravascular volume? Resident: Hmm.... I’m actually not sure. You’re right, though, it doesn’t make sense. Attending: I agree. Let’s pause and think about how we are thinking about this case .

To a large degree, recognition of cognitive bias requires metacognition, defined as thinking about one’s thinking ( 3 , 16 , 27 ). This process is optimized with a familiarity with how the mind works; that is, a basic understanding of dual-process theory and cognitive biases. In the ICU, we find it easiest to engage in a group metacognition exercise. The attending asks, “How are we thinking about this case?” This allows both the attending and the team to reflect together on how and why the diagnosis has been made. This can provide insight into the tendency to prematurely close or limit considerations, which has been shown to be the most common cause of inaccurate clinical synthesis ( 10 ).

Other debiasing strategies include accountability ( 6 ) and feedback ( 25 , 30 ). Giving specific and in-the-moment feedback can help residents understand their decisions ( 25 ). It is our job as attendings to provide this feedback, and it is thought that this is one of the most effective debiasing strategies ( 25 ).

Strategy 3: Model and Teach Inductive Reasoning

In medicine, we classically teach clinical reasoning via the hypothetico-deductive strategy ( 31 ) and rarely discuss inductive reasoning. To date, there are no data proving the advantages of one strategy over another, but we believe that modeling inductive reasoning is an important part of critical thinking, especially when type 1 thinking provides limited answers. In hypothetico-deductive reasoning, physicians make a cognitive jump from a few facts to hypotheses framed as a differential diagnosis from which one then deduces characteristics that are matched to the patient ( 32 ). Because this way of thinking relies on memory and pattern recognition, we find that it is more subject to cognitive biases, including premature closure, than inductive reasoning.

In our case, the presence of hypotension leads the trainee to come up with a differential based primarily on that single observation; the resident thinks of diagnoses such as sepsis or cardiogenic shock. Contrast this way of thinking with inductive reasoning, which proceeds in an orderly way from multiple facts to hypotheses ( 32 ). In our case, putting together the facts of hypotension, decreased hematocrit, and elevated blood urea nitrogen/creatinine would lead to a broader list of possible explanations or hypotheses that would include bleeding (see Figure 3 to compare and contrast inductive and deductive reasoning). We propose that this way of thinking is grounded more deeply in pathophysiology, and we believe it leads to broader thinking, because trainees do not have to rely on memory, pattern recognition, or heuristics; rather, they can reason their way through the problem via an understanding of basic mechanisms of health and disease.

Schematic representations of deductive ( 1 ) and inductive ( 2 ) reasoning apropos to the clinical case. In deductive reasoning, one fact ( F ; hypotension ) is used to generated multiple hypotheses ( H ), and then facts that pertain to each are retrofitted ( red F* ; fever ). In inductive reasoning, facts are grouped and used to generate hypotheses. Adapted from Pottier ( 32 ).

Inductive reasoning can be practiced using both mechanism and concept maps. Mechanism maps are a visual representation of how the pathophysiology of disease leads to the clinical symptoms ( 33 ), whereas concept maps graphically represent relationships between multiple concepts ( 33 ) and make links explicit. Both types reinforce mechanistic thinking and can be used as tools to avoid cognitive biases. Using our case as an example, if the resident started with the hypotension and made a mechanism ( Figure 4A ) or concept ( Figure 4B ) map, she would be less likely to anchor on the diagnosis of sepsis. This process gives trainees a strategy to broaden their differential and a way to think about the case when they do not know what is going on.

( A ) A mechanism map of a 45-year-old man presenting with cough, shortness of breath. Found to have an increased BUN/Cr ration, a decreased hematocrit, and a normal white blood cell count. ( B ) A concept map of the clinical case. AFib = atrial fibrillation; BUN/Cr = blood urea nitrogen to creatinine ratio; CAD = coronary artery disease; CO/Q = cardiac output; CVP = central venous pressure; CXR = chest X-ray; GI = gastrointestinal; HR = heart rate; Hx HTN = history of hypertension; MAP = mean arterial pressure; RV = right ventricle; SV = stroke volume; SVR = systemic vascular resistance; WBC = white blood cell.

Although critics contend that these maps take time and do not have a place in the ICU, we find that quickly sketching a mechanism map on rounds while the case is being presented only takes 1–2 minutes and is a powerful way of making your method of clinical reasoning explicit to the learner. This can also be done later as a way to review pathophysiology. We hold monthly concept mapping sessions for our students ( 34 ) to improve their clinical reasoning skills, but find that in the ICU with residents, doing this quickly in real time with a mechanism map is more effective.

Strategy 4: Use Questions to Stimulate Critical Thinking

Questions can be used to engage the learners and inspire them to think critically. When questioning trainees, it is important to avoid the “quiz show” type questions that just test whether a trainee can recall a fact (e.g., “What is the most common cause of X”?). In our current advanced technological age, answers to this type of question reveal less about thinking abilities than how adept one is at searching the internet. These questions do not provide insight into the trainee’s understanding but can, we fear, subtly emphasize that the practice of medicine is about memorization, rather than thinking. In addition, this type of question is often perceived by the trainee as “pimping.” This can belittle the trainee while securing the attending physician’s place of power ( 35 ) and create a hostile learning environment.

Attending: Why do you think this patient is hypotensive? Attending: How does the BUN/creatinine ratio relate to the hypotension? Attending: How would you expect the intravascular volume depletion to affect his hematocrit?

Questions like these allow the trainee to elaborate on her knowledge, which feels much safer to the learner and provides the attending insight into her thinking.

Resident: If my theory of sepsis were correct, I would think the patient would be intravascularly dry and have a higher hematocrit. The fact that it is only 35% and that his BUN/creatinine ratio is consistent with a prerenal picture is making me worried that maybe the hypotension is not from sepsis but, rather, from bleeding. I think we need to evaluate for gastrointestinal bleeding.

When the right questions are used to coach the resident, her thought processes are uncovered and she can be guided to the correct diagnosis. Although experience and domain-specific knowledge are important, data indicate that in the majority of malpractice cases involving diagnostic error, the problem is not that the doctor did not know the diagnosis; rather, she did not think of it. Reasoning, rather than knowledge, is key to avoiding mistakes in cases with confounding data.

Strategy 5: Assess Your Learner’s Critical Thinking

It is difficult, but necessary for trainee development, to assess critical thinking ( 18 ). Milestones, ranging from challenged and unreflective thinkers to accomplished critical thinkers, have been proposed ( 18 ). This approach is helpful not only for providing feedback to trainees on their critical thinking but also to give the trainees a framework to guide reflection on how they are thinking (see Table 2 for a description of the milestones).

Milestones of critical thinking and the descriptions of each stage

Note that “Challenged thinker” is in italics because any thinker can be challenged as a result of environmental pressures or time constraints. Adapted from Papp ( 18 ).

It is important to note that anyone, even accomplished critical thinkers, can become “challenged critical thinkers” when the environment precludes critical thinking. This is particularly relevant in critical care. In a busy ICU, one is often faced with time pressure, which contributes to premature closure. In our case presented earlier, perhaps the resident had limited time to admit this patient, and thus settled on the diagnosis of sepsis. It is our hope that teaching trainees to recognize this risk will lead to fewer cognitive biases. Imagine a different exchange between faculty and resident:

Attending: How are you doing with the new admission? How are you thinking about the case? Resident: I’m concerned this is sepsis, but there are few pieces that don’t fit. However, given the two other admissions and the cardiac arrest on the floor who is heading our way, I haven’t been able to give this case as much thought as I would like to. Attending: Okay, do you want to work through the case together? Or could I help with some other tasks so you have more time to think about this?

This type of response reflects a practicing critical thinker: one who is aware of her limitations and thinking processes. This can only occur, however, if the attending creates an environment in which critical thinking is valued by making a safe space and asking the right questions.

Conclusions

The ICU is a high-acuity, fast-paced, and high-stakes environment in which critical thinking is imperative. Despite the limited empirical evidence to guide faculty on best teaching practices for enhancing reasoning skills, it is our hope that these strategies will provide practical approaches for teaching this topic in the ICU. Given how fast medical knowledge grows and how rapidly technology allows us to find factual information, it is important to teach enduring principles, such as how to think.

Our job in the ICU, where literal life-and-death decisions are made daily, is to teach trainees to focus on how we actually think about problems and to uncover cognitive biases that cause flawed thinking and may lead to diagnostic error. The focus of the preclerkship curriculum at the undergraduate level is increasingly moving away from transfer of content to application of knowledge ( 36 ). When teaching residents and fellows, faculty should also emphasize thinking skills by making the thinking process explicit, discussing cognitive biases, and debiasing strategies, modeling and teaching inductive reasoning, using questions to stimulate curiosity, and assessing critical thinking skills.

As Albert Einstein said, “Education... is not the learning of facts, but the training of the mind to think...” ( 38 ).

Supplementary Material

Author Contributions : M.M.H. contributed to manuscript drafting, figure creation, and editing; S.C. contributed to figure creation, critical review, and editing; and R.M.S. contributed to figure creation, critical review, and editing.

Author disclosures are available with the text of this article at www.atsjournals.org .

Teaching in the ICU

• First Online: 15 May 2019

Cite this chapter

• William Graham Carlos III 6 &
• Emily Cochard 6  

Part of the book series: Respiratory Medicine ((RM))

818 Accesses

The complexity of the intensive care unit (ICU) environment provides ample opportunity for teaching learners. The challenge lies in tailoring different teaching methods to an audience with a varying knowledge base. This chapter aims to address teaching learners throughout their ICU experience. The reader will discover how to set the stage with an orientation, to find teaching moments at and away from the bedside, and to give individual as well as team feedback.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Subscribe and save.

• Get 10 units per month
• Download Article/Chapter or Ebook
• 1 Unit = 1 Article or 1 Chapter
• Cancel anytime
• Available as PDF
• Read on any device
• Instant download
• Own it forever
• Available as EPUB and PDF
• Durable hardcover edition
• Dispatched in 3 to 5 business days
• Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

Teaching in a Busy Clinical Setting

How to Teach at the Bedside

Oriol MD. Crew resource management: applications in healthcare organizations. JONA. 2006;36(9):402–6.

Article   Google Scholar  

Schull MJ, Ferris LE, Tu JV, Hux JE, Redelmeier DA. Problems for clinical judgment: 3. Thinking clearly in an emergency. CMAJ. 2001;164(8):1170–5.

CAS   PubMed   PubMed Central   Google Scholar  

Reader TW, Cuthbertson BH. Teamwork and team training in the ICU: where do the similarities with aviation end? Crit Care. 2011;15:313.

Nedrow A, Steckler NA, Hardman J. Physician resilience and burnout: can you make the switch. Fam Pract Manag. 2013;20:25–30. www.aafp.org/fpm .

PubMed   Google Scholar  

Moss M, Good VS, Gozal D, Kleinpell R, Sessler CN. A critical care societies collaborative statement: burnout syndrome in critical care health-care professionals. A call for action. Am J Respir Crit Care Med. 2016;194(1):106–13.

Eisendrath SJ, Link N, Matthay M. Intensive care unit: how stressful for physicians? Crit Care Med. 1986;14(2):95–6.

Article   CAS   Google Scholar  

Wolfe KK, Unti SM. Critical care rotation impact on pediatric resident mental health and burnout. BMC Med Educ. 2017;17:181.

Fargen KM, Spiotta AM, Turner RD, Patel S. The importance of exercise in the well-rounded physician: dialogue for the inclusion of a physical fitness program in neurosurgery resident training. World Neurosurg. 2016;90:380–4.

Lebensohn P, Dodds S, Benn R, Brooks AJ, Birch M, Cook P, Schneider C, Sroka S, Waxman D, Maizes V. Resident wellness behaviors: relationship to stress, depression, and burnout. Fam Med. 2013;45(8):541–9.

Davidson JE. Family presence on rounds in neonatal, pediatric, and adult intensive care units. Ann Am Thorac Soc. 2013;10(2):152–6.

Jacobowski NL, Girard TD, Mulder JA, Ely EW. Communication in critical care: family rounds in the intensive care unit. Am J Crit Care. 2010;19:421–30.

Carlos WG, Kritek PA, Clay AS, Luks AM, Thomson CC. Teaching at the bedside: maximal impact in minimal time. Ann Am Thorac Soc. 2016;13(4):545–8.

Google Scholar  

Piquette D, Moulton C, LeBlanc VR. Model of interactive clinical supervision in acute care environments: balancing patient care and teaching. Ann ATS. 2015;12(4):498–504.

Hayes MM, Chatterjee S, Schwartzstein RM. Critical thinking in critical care: five strategies to improve teaching and learning in the intensive care unit. Ann Am Thorac Soc. 2017;14(4):569–75.

Verghese A, Brady E, Kapur CC, Horwitz RI. The bedside evaluation: ritual and reason. Ann Intern Med. 2011;155:550–3.

Chi J, Verghese A. Clinical education and the electronic health record: the flipped patient. JAMA. 2014;312:2331–2.

Block L, Habicht R, Wu AW, et al. In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time? J Gen Intern Med. 2013;28:1042–7.

Chi J, Artandi M, Kugler J, Ozdalga E, Hosamani P, Koehler E, Osterberg L, Zaman J, Thadaney S, Elder A, Verghese A. The five-minute moment. Am J Med. 2016;129(8):792–5.

Narasimhan M, Koenig SJ, Mayo PH. A whole-body approach to point of care ultrasound. Chest. 2016;150(4):772–6.

Frankel HL, Kirkpatrick AW, Elbarbary M, Blaivas M, Desai H, Evans D, Summerfield DT, Slonim A, Breitkreutz R, Price S, Marik PE, Talmor D, Levitov A. Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients-part I: general ultrasonography. Crit Care Med. 2015;43(11):2479–502.

Levitov A, Frankel HL, Blaivas M, Kirkpatrick AW, Su E, Evans D, Summerfield DT, Slonim A, Breitkreutz R, Price S, McLaughlin M, Marik PE, Elbarbary M. Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients-part II: cardiac ultrasonography. Crit Care Med. 2016;44(6):1206–27.

So S, Patel RM, Orebaugh SL. Ultrasound imaging in medical student education: impact on learning anatomy and physical diagnosis. Anat Sci Educ. 2016;10(2):176–89.

Hoppmann RA, Rao VV, Poston MB, Howe DB, Hunt PS, Fowler SD, Paulman LE, Wells JR, Richeson NA, Catalana PV, Thomas LK, Wilson LB, Cook T, Riffle S, Neuffer FH, McCallum JB, Keisler BD, Brown RS, Gregg AR, Sims KM, Powell CK, Garber MD, Morrison JE, Owens WB, Carnevale KA, Jennings WR, Fletcher S. An integrated ultrasound curriculum (iUSC) for medical students: 4-year experience. Crit Ultrasound J. 2011;3:52.

Wilson SP, Mefford JM, Lahham S, Lotfipour S, Subeh M, Maldonado G, Spann S, Fox JC. Implementation of a 4-year point-of-care ultrasound curriculum in a liaison committee on medical education-accredited US medical school. J Ultrasound Med. 2017;36(2):321–5.

Torre DM, Simpson D, Sebastian JL, Elnicki DM. Learning/feedback activities and high-quality teaching: perceptions of third year medical students during an inpatient rotation. Acad Med. 2005;80:950–4.

Wayne DB, Butter J, Siddall VJ, Fudala MJ, Linquist LA, Feinglass J, Wade LD, McGaghie WC. Simulation-based training of internal medicine residents in advanced cardiac life support protocols: a randomized trial. Teach Learn Med. 2005;17(3):202–8.

Wayne DB, Butter J, Siddall VJ, Fudala MJ, Wade LD, Feinglass J, McGaghie WC. Master learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice. J Gen Intern Med. 2006;21:251–6.

Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JF, McGaghie WC. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest. 2008;133:56–61.

Barsuk JH, McGaghie WC, Cohen ER, O’Leary KJ, Wayne DB. Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. Crit Care Med. 2009;37:2697–701.

Sekiguchi H, Tokita JE, Minami T, Eisen LA, Mayo PH, Narasimhan M. A prerotational, simulation-based workshop improves the safety of central venous catheter insertion: results of a successful internal medicine house staff training program. Chest. 2011;140(3):652–8.

Mayo PH, Hackney JE, Mueck JT, Ribaudo V, Schneider RF. Achieving house staff competence in emergency airway management: results of a teaching program using a computer patient simulator. Crit Care Med. 2004;32(12):2422–7.

Rosenthal ME, Adachi M, Ribaudo V, Mueck JT, Schneider RF, Mayo PH. Achieving house staff competence in emergency airway management using scenario based simulation training. Chest. 2006;129:1453–8.

Cheng A, Hunt EA, Donoghue A. Examining pediatric resuscitation education using simulation and scripted debriefing: a multicenter randomized trial. JAMA Pediatr. 2013;167(6):528–36.

Barsuk JH, Cohen ER, Potts S, Demo H, Gupta S, Feinglass J, McGaghie WC, Wayne DB. Dissemination of a simulation-based mastery learning intervention reduces central line-associated bloodstream infections. BMJ Qual Saf. 2014;23:749–56.

Schroedl CJ, Corbridge TC, Cohen ER, Fakhran SS, Schimmel D, McGaghie WC, Wayne DB. Use of simulation-based education to improve resident learning and patient care in the medical intensive care unit: a randomized trial. J Crit Care. 2012;27:219.e7–219.e13.

Kleinpell R, Ely EW, Williams G, Liolios A, Ward N, Tisherman SA. Web-based resources for critical care education. Crit Care Med. 2011;39(3):541–53.

Carlos WG, Goss K, Morad M. YouTube-based critical care videos go viral. Academic Medicine; Really Good Stuff Section. Med Educ. 2014;48:522–8.

About TeamSTEPPS®. Content last reviewed April 2017. Rockville: Agency for Healthcare Research and Quality. http://www.ahrq.gov/teamstepps/about-teamstepps/index.html .

Horsley TL, Reed T, Muccino K, Quinones D, Siddall VJ, McCarthy J. Developing a foundation for interprofessional education within nursing and medical curricula. Nurse Educ. 2016;41(5):234–8.

Mayer CM, Cluff L, Lin WT, Willis TS, Stafford RE, Williams C, Saunders R, Short KA, Lenfestey N, Kane HL, Amoozegar JB. Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units. Jt Comm J Qual Patient Saf. 2011;37(8):365–74.

Clay AS, Que L, Petrusa ER, Sebastian M, Govert J. Debriefing in the intensive care unit: a feedback tool to facilitate bedside teaching. Crit Care Med. 2007;35(3):738–54.

Thistlethwaite J, Dallest K, Moran M, Dunston R, Roberts C, Eley D, Bogossian F, Forman D, Bainbridge L, Drynan D, Fyfe S. Introducing the individual Teamwork Observation and Feedback Tool (iTOFT): development and description of a new interprofessional teamwork measure. J Interprof Care. 2016;30(4):526–8.

Download references

Author information

Authors and affiliations.

Indiana University School of Medicine, Indianapolis, IN, USA

William Graham Carlos III & Emily Cochard

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to William Graham Carlos III .

Editor information

Editors and affiliations.

University of Washington, Seattle, WA, USA

Patricia A. Kritek

Harvard University, Boston, MA, USA

Jeremy B. Richards

Rights and permissions

Reprints and permissions

Copyright information

© 2019 Springer Nature Switzerland AG

About this chapter

Carlos, W.G., Cochard, E. (2019). Teaching in the ICU. In: Kritek, P., Richards, J. (eds) Medical Education in Pulmonary, Critical Care, and Sleep Medicine. Respiratory Medicine. Humana, Cham. https://doi.org/10.1007/978-3-030-10680-5_10

Download citation

DOI : https://doi.org/10.1007/978-3-030-10680-5_10

Published : 15 May 2019

Publisher Name : Humana, Cham

Print ISBN : 978-3-030-10679-9

Online ISBN : 978-3-030-10680-5

eBook Packages : Medicine Medicine (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Publish with us

Policies and ethics

• Find a journal
• Track your research

The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter, DNP, APRN, ACNS-BC, CNE

Crystal Slaughter is a core faculty member in Walden University’s RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter’s clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

• Open Access
• By Publication (A-Z)
• Case Reports
• Publication Ethics
• Publishing Policies
• Editorial Policies
• Submit Manuscript
• About Graphy

New to Graphy Publications? Create an account to get started today.

Registered Users

Have an account? Sign in now.

• Full-Text HTML
• Full-Text PDF
• About This Journal
• Aims & Scope
• Founding Board
• Editorial Board
• Editorial Process
• Author Guidelines
• Special Issues
• Articles in Press

Yu-Ching Yang 1 , Hui-Man Huang 2,* and Tzu-Chi Chen 3

Background: Intensive care unit (ICU) nurses must think critically in order to identify and deal with patients problems and thus provide better care. Currently, however, no existing research has explored ICU nurses’ critical thinking skills and caring behaviors. Purpose: To investigate the associations among the personal characteristics, critical thinking skills, and caring behaviors of ICU nurses in Taiwan. Methods: A cross-sectional correlational study was conducted. A convenience sample of 352 ICU nurses was recruited from three hospitals in southern Taiwan. Data were collected using self‐report measures including a Personal Characteristics Questionnaire, the Critical Thinking Skills Scale, and the Caring Behaviors Scale. Results: (a) The critical thinking skills and caring behaviors of the ICU nurses were found to be “moderate”, with index scores of 52.5 and 65.6, respectively. (b) The nurses’ overall critical thinking skills were associated by their clinical ladder, with their “Inference skills” being affected by their seniority and their “Interpretation skills” being affected by their position titles. (c) Their caring behaviors were affected by their age, marital status, clinical ladder, hospital work seniority, and ICU work seniority. (d) Their critical thinking skills and caring behaviors were not associated. Conclusions: In the healthcare sector, managers should seek to enhance ICU nurses’ critical thinking skills and teach them specific behaviors to help them better care for ICU patients.

1. Introduction

Caring is considered a universal need, the essence of nursing, and an important component in the delivery of nursing care [3] . Through their interactions with patients, nurses care for them, attempt to understand and satisfy their needs, and provide patient-centered holistic care [4] . However, because ICU nurses generally have busy schedules, they typically focus on solving their patients’ physiological problems, usually the more pressing ones, and are often forced to overlook their patients’ emotional needs. Consequently, patients may sometimes feel neglected and lose their trust in ICU nurses [5] .

Regardless of the specific nursing paradigms in which they work, ICU nurses must have both critical thinking skills and caring skills [5] . Past studies have shown that there is a positive relationship between overall critical thinking skills and caring behaviors in nursing students [6 - 8] . However, no research has simultaneously investigated the skills needed for critical thinking and the caring behavior of nurses working in ICUs specifically. Therefore, the present study was conducted in order to examine the critical thinking skills and caring behavior of ICU nurses.

2. Literature Review

2.1 critical thinking skills.

Critical thinking is a goal-oriented high-level thinking activity that involves knowledge, attitudes, and analysis [9] . Critical thinking skills entail carefully assessing a client’s problem, confirming and generalizing relevant evidence, evaluating the accuracy of evidence through logical inference, and determining the appropriate way to solve the problem [10] . Similar to the nursing process, critical thinking uses a systematic approach to solving problems. It is a patient-centered assessment mechanism through which nurses integrate the collected data, apply professional knowledge to identify crucial clues, and then propose an optimal problem-solving strategy. Critical thinking skills are fundamental skills that nurses use when making independent judgments [11 , 12] . At the same time, the personal characteristics of nurses, e.g., age, education, position title, and seniority, have been confirmed to affect their critical thinking skill.

2.2 Caring behaviors

Caring is a specific simultaneous manifestation of thoughts and behaviors that enable nurses to regard others as independent entities and to care for them during interactions [15 , 16] . From the perspective of human science, caring is the essence of nursing and a type of moral concept that emphasizes the importance of nurse-patient interactions [17] . Leininger [18] and Nelson [19] stressed that cultural care exhibits universality and diversity and that individualized care should be provided from a patient-centered perspective in order to conform to the concept of culturally congruent care. Caring refers to the behavior that nurses exhibit at various levels after making assessments and judgments based on their professional knowledge and skills. For example, nurses show caring behavior as they assist patients throughout the trajectories of their illnesses. In addition, caring requires nurses to be sensitive when identifying the potential and immediate needs of patients. Moreover, nurses must emphasize the importance of patients’ rights, satisfaction, and needs, and they must have problem-solving skills that promote patient health. Meanwhile, it has previously been observed that nursing care is influenced by the specific characteristics of individual nurses [20] . Studies from around the world, in fact, have confirmed that the personal characteristics of nurses, such as their level of education [3 , 21] , religious beliefs [22] , marital status [21] , age [17] , position title [21] , and job seniority [3 , 23] affect their caring performance.

2.3 The correlation between critical thinking skills and caring behaviors

Critical thinking is widely accepted as being associated with the provision of quality care [24] . Thayer-Bacon [25] indicated that without caring, an individual cannot hope to be an effective critical thinker. ICU nurses must be capable of critical thinking and of demonstrating the effectiveness of their caring behavior [5] . However, prior research regarding both critical thinking skills and caring behaviors has generally focused on nursing students only. For example, the past literature has reported a positive relationship between overall critical thinking skills and caring behaviors in nursing students [6 - 8] . Relatedly, Chen, Chang, and Pai [26] found that caring behaviors directly and indirectly affect nursing students’ critical thinking.

Meanwhile, other researchers who have explored critical thinking skills have focused exclusively on clinical nurses [2 , 13] . These studies report a significant relationship between critical thinking and demographic characteristics such as age, years of nursing experience, experiences in other hospitals, and clinic ladder etc. No studies have addressed both ICU nurses’ critical thinking skills and caring behaviors. Moreover, even though we know that critical thinking skills and caring behaviors are correlated in nursing students, the association between critical thinking skills and caring behaviors in ICU nurses remains unclear. Therefore, the current study was conducted in order to provide nursing administrators with advanced information and to enable ICU nurses to more actively develop the skills needed for critical thinking and caring behavior. The specific aims of this study were to: (1) describe the critical thinking skills and caring behaviors among ICU nurses in Taiwan, (2) study whether the personal background characteristics of such nurses have any impact on their critical thinking skills and caring behaviors, and (3) explore the correlation between critical thinking skills and caring behaviors among ICU nurses in Taiwan. The findings of this study might thus serve as a reference to nursing managers for planning in-service educational courses.

3.1 Design, setting and subjects

This cross-sectional correlational study was conducted from August 25, 2014, to September 22, 2014. Convenience sampling was used for the study. With the exclusion of head nurses and physicians’ assistants, the participants in this study consisted of ICU nurses from three foundation hospitals (one medical center, one regional hospital, and one district hospital) in southern Taiwan. All of the participants were licensed practical nurses (2.6%) or registered nurses (97.4%) with at least 3 months of ICU experience. Four hundred thirty-six questionnaires were distributed to ICU nurses, of which 390 (89.45%) were returned. After the incomplete questionnaires had been eliminated, 352 valid questionnaires remained, for a response rate of 80.73%.

4. Main Outcome Measures

4.1 personal characteristics questionnaire.

The Personal Characteristics Questionnaire was designed to elicit information on the participants’ gender, age, level of education, religious beliefs, marital status, position title, work unit, hospital level, total clinical seniority, total ICU seniority,and clinical ladder (N = lowest ranking; N4 = highest ranking). The clinical ladder system was designed to meet the professional needs of nurses, bring stability for nurses in the workplace, ensure nurses are assigned to proper positions and promote nursing quality.

4.2 Critical Thinking Skills Scale

The Critical Thinking Skills Scale revised by Zheng et al. [9] is divided into five parts: Inference, Recognition of assumption, Deduction, Interpretation, and Evaluation of argument. This scale, with its five subscales, was shown to be effective in measuring the critical thinking skills of clinical nurses in a study conducted by Chang et al. [2] . Each part of the scale is comprised of 12 questions (total: 60 questions). Each question on “Inference” asks the given respondent to select one of five possible answers; the questions in the other four parts ask the respondent to select one of two answers. Each correct answer receives a score of 1 point, so the maximum possible score is 60. Higher scores indicate greater critical thinking skills. The Cronbach’s α of this scale was found to be .71 in the aforementioned study by Chang et al. [2] and .78 in the present study. Both scores indicated that the scale is sufficiently reliable.

4.3 Caring Behaviors Scale

The present study also used the Caring Behaviors Scale (CBS) [27] , which contains three dimensions: “knowing patients’ needs”, “helping patients through the illness trajectory”, and “serving as a patient advocate”. In a 2011 study by Lin, these dimensions were shown to be significant in measuring the caring behavior of clinical nurses. The CBS includes 28 questions, each of which is scored on a 4-point scale, where 3 = always (performance frequency > 80%); 2 = often (performance frequency > 50%); 1 = occasionally (performance frequency > 20%); and 0 = never (performance frequency = 0%). The total score ranges from 0 to 84, with higher scores indicating better caring behaviors. The Cronbach’s α for this scale was found to be .96 in the aforementioned study by Lin [21] and .95 in the present study, which indicated that the scale was acceptably reliable.

4.4 Ethical considerations

Before the present study was conducted, official permission was obtained from the administrators of the hospitals in which the study was conducted and from our own hospital’s Hospital Ethics Committee (Document No.: 10212-016). The nurses who answered the questionnaires did so anonymously and gave their written consent to participate in the study.

4.5 Data analysis

SPSS 20.0 for Windows was used for all analyses. Descriptive statistics (percentage, mean, and standard deviation), t tests, analysis of variance (ANOVA), and Pearson’s product-moment correlation tests were also used.

5.1 Personal characteristics of ICU nurses

As shown in Table 1, the analysis of the personal characteristics of the 352 ICU nurses showed that 93.8% (n= 330) were female, their average age was 29.2±4.86 years, and more than one-third (34.4%) were aged between 26 and 30 years. A great majority (97.2%) had graduated from university or received a higher level of education, 63.6% were Taoist, and 69.9% were unmarried. Most (76.7%) were non-managers, and some were N3 nurses (28.4%). More than half were currently working in an internal medicine ICU (52.0%) and were employed at a medical center (59.7%); 38.1% had 1-5 years of clinical experience, and 44.9% had worked for 1-5 years in ICUs.

5.2 Critical thinking skills and caring behaviors

The means and standard deviations for each of the five critical thinking skills and the overall mean score are presented in Table 2. The overall critical thinking skill of ICU nurses was found to be “moderate”, with a mean score of 31.51±7.33, and an index score of 52.5 (31.51/60 × 100=52.5). Among the subscales, the mean subscore was highest for Recognition of assumption (7.36) and lowest for Inference (5.31). The nurses had moderate perceptions of caring behaviors. The average overall score for caring behavior was 55.07±11.65, with an index score of 65.6 (55.07/84 × 100=65.6) (Table 2). Among all the subscales, the average value as highest for “knowing the patient’s needs” (1.99) and lowest for “helping patient through the illness trajectory” (1.95).

5.3 Relationships between personal characteristics and critical thinking skills, caring behaviors

Statistical analysis was performed to determine whether the personal characteristics of the nurses had any impacts on their critical thinking skills and caring behaviors. As shown in Table 3, the N2 and N3 nurses were found to have greater critical thinking skills than the N4 nurses. Meanwhile, the non-managers showed stronger Interpretation skills than did the managers (group leaders, associated head nurses, and nurse practitioners). Furthermore, the ICU nurses who had worked for 1-5 and 6-9 years exhibited greater Inference skills than did those who had worked for less than 1 year or more than 10 years.

The results presented in Table 4 demonstrated that the caring behavior performances of the ICU nurses who were married and aged 31-40 years old were better than those of the nurses who were single and who were younger than 25 years old. The N4 nurses showed better caring behavior performances than the N and N1 nurses. The N3 nurses showed better caring behavior performances than the N1 nurses. The nurses who had been involved in clinical work for over 10 years showed better caring behavior performances than those who had worked for less than 1 year, 1-5 years, or 6-9 years. Those who had worked for 6-9 years scored higher on this dimension than those who had worked for less than 1 year or 1-5 years. In addition, the nurses who had worked in ICUs for over 10 years showed higher caring behavior performances than those who had worked for less than 1 year or 1-5 years.

5.4 Correlation between critical thinking skills and caring behaviors

The results presented in Table 5 illustrated that there was no significant correlation between the critical thinking skills and caring behaviors of the ICU nurses.

6. Discussion

6.1 analyzing critical thinking skills and caring behaviors of icu nurses.

We found that the mean score for critical thinking skills (31.51) in this study was lower than the 40.16 mean reported by Chang et al. [2] . Hospitals of different types and levels have distinct organizational cultures. The case hospitals sampled in the present study were foundation hospitals (including one medical center, one regional hospital, and one district hospital), which differ from the affiliated university hospital sampled by Chang et al. [2] . Therefore, the differences in the organizational cultures of the hospitals investigated in the two studies might explain the lower critical thinking scores attained by the nurses in the present study.

The average overall score for the caring behaviors of the ICU nurses in this study was 55.07 (with an index score of 65.6), which was lower than the 79.49 average overall score (with an index score of 73.6, out of a possible total mean score of 108) reported by Lin [21] for nurses working at a regional teaching hospital. Meanwhile, most of the participants in the present study had less than 9 years of clinical experience (69.3%; 244 nurses), whereas nearly half of the participants in the study by Lin [21] had at least 10 years of clinical experience (49.6%). This difference in the seniority and educational level of the participants in the two studies might have caused the difference in the quality of their caring behaviors. Among the subscales of the CBS, the score for the “Knowing the patient’s needs” subscale was the highest while that for the “Helping patients through the illness trajectory” subscale was the lowest, suggesting that the more observable aspects of care received the higher ratings. These results were consistent with those of Li et al. [17] and Lin [21] but differed from those of Lee et al. [28] . This difference might have been because most of the critically ill ICU patients in the present study were intubated and, therefore, unable to directly express their needs. Relatedly, because of the unique characteristics of ICU patients, ICU nurses must be able to detect the needs of patients, ascertain the focus of care according to their nursing experience, and quickly satisfy the patients’ needs.

6.2 Analyzing the relationships among personal characteristics and critical thinking skills and caring behaviors

The N2 and N3 ICU nurses showed better critical thinking skills than did the N4 nurses, results which differed from the findings of Chang et al. [2] and Feng et al. [13] . In exploring the decision-making skills of head nurses from the perspectives of nurses, Lin et al. [29] reported that intuitive decision-making skills stem from accumulated experience and professional knowledge. Moreover, higher-level nurses often make decisions intuitively. Because the participants in the present study were from different work units, most of the N4 ICU nurses had considerable specialized care experience, which enabled them to intuitively analyze their patients’ problems and quickly formulate potential solutions. Consequently, the critical thinking skills of N2 and N3 ICU nurses were greater than those of the N4 nurses.

Among the subscales of the Critical Thinking Skills Scale, the score for the “Recognition of assumption” subscale was the highest, which indicated that the ICU nurses’ had greater skills for identifying evidence to assist physicians in assessing changes in the conditions of patients’ problems than they had in the other four skill areas. Similar to the findings reported by Chang et al. [2] , the nurses in this study scored the lowest for the “Inference” subscale, which suggested that the inference skills of these ICU nurses were unsatisfactory. This might be because each of the “Inference” questions had five possible answers, whereas those for the other four subscales had only two possible answers each. This difference in the number of available answers might have caused the “Inference” scores to be the lowest. In addition, the low “Inference” scores might also have been attributable to a lack of instruction in how to make reasonable inferences in clinical settings; relatedly, clinical case conferences were rarely held in these nurses’ workplaces. The non-manager ICU nurses showed better Interpretation skills than did the managers, possibly because managers generally focus on administrative work and rarely participate in direct patient care. Furthermore, because ICU work is patient- and situation-centered rather than mechanical, non-managers can continually think critically and formulate new interpretations when they provide patient care. Similar to the findings reported by Chang et al. [2] and Feng et al. [13] , the Inference skills of the ICU nurses in this study varied significantly with their total ICU seniority, which indicated that the nurses with more seniority were better at thinking critically when providing patient care in the ICU.

The age of the ICU nurses in the present study had a significant effect on their caring behaviors, a finding which was consistent with the findings of Li et al. [17] , Lin [21] , and Lee et al. [28] . Specifically, the results indicated that the older nurses typically had more extensive clinical experience and that they could provide care based on their professional skills, promote patient health, and offer better caring behavior. Meanwhile, the past literature suggested that married people generally have a stronger sense of responsibility in caring for their families compared with those who are unmarried. In our study, relatedly, nurses who were married had caring behaviors that were better than those of unmarried nurses, which is consistent with Ma’s [30] findings.

A previous report suggested that caring behavior is associated with working experience. This study found that the N4 nurses demonstrated better caring behaviors than did the N and N1 nurses, and that the N3 nurses showed better caring behavior than did the N1 nurses, findings which were consistent with the findings of Chi et al. [31] . These results also revealed that the nurses working at higher clinical levels exhibited more satisfactory caring behavior. Moreover, this study found that overall clinical and ICU seniority had a significant effect on the caring behaviors of the nurses: those with higher seniority showed better caring behaviors than did those with lower seniority. These results support those of a study by Lee et al. [28] , but differ from those of Lin [21] . This might have been because the ICU nurses in the present study were continually learning and accumulating caregiving experience during work and appropriately performing their care functions, which could have improved their caring behavior performances.

Previous studies have reported that there was a significant relationship of educational background with critical thinking skills and caring behaviors [2 , 3 , 13 , 21] . However, our results were not consistent with those findings of similar previous studies, as the results of this study suggested that education level was not correlated with the critical thinking skills and caring behaviors of the ICU nurses. This difference might have been because only 10 nurses (3.8%) in this study not had university certification or a higher level of education. The number of ICU nurses in two compared educational groups varies widely. Therefore, there was no significant difference shown in the results. The nurses’ overall critical thinking skills were associated by their clinical ladder, seniority and position titles. That said, the overall results of this study did suggest that the ICU nurses’ critical thinking skills and caring bahaviors were influenced by their personal characteristics.

6.3 Association between critical thinking skills and caring behaviors

Previous reports have advocated the view that more satisfactory caring behaviors indicated better critical thinking skills in nursing students [6 , 8 , 26] , but the results of this study indicated that the critical thinking skills of the ICU nurses and their caring behaviors were not significantly correlated. The reason for the contrast between these results and those of previous reports might be that, firstly, the participants in the present study were ICU nurses, whereas those in the studies by Arli et al. [6] , Chen et al. [26] , and Pai et al. [7] were nursing students. Secondly, caring behavior in this study included knowing patients’ needs, helping patients through the trajectories of their illnesses, and serving as a patient advocate. Our results were consistent with those of a previous study by Lin [21] using the same indicators. However, the relevant behaviors were not routinely performed by the ICU nurses in daily practice. Previous studies have shown that the caring behavior of nurses is significantly influenced by the personal characteristics of nurses [20 , 32] . Moreover, caring behavior and critical thinking skills are different abilities. The caring behavior of nurses is one of the humanistic literacy. But today, many nurses’ humanistic quality is declining and a lot of colleges don’t pay much attention to the humanity cultivation of the university’s nursing students. On the other hands, critical thinking skill is concerned about problem-based learning and to learning logical reasoning as well as being able to improve problem-solving abilities [33] . It is difficult to improve ICU nurses in the critical thinking skill and the humanistic quality at the same time.

Finally, the Critical Thinking Skills Scale revised by Zheng et al. [9] and used in the present study differed from the Critical Thinking Disposition Inventory, Chinese Version(CTDI-CV) adopted by Pai et al. [7] . The concepts within these two instruments are not identical. Pai et al. [7] intended to measure the critical thinking characteristics of the participants in their study in terms of seven dispositions: truth-seeking, open-mindedness, analyticity, systematicity, selfconfidence, inquisitiveness, and maturity. In contrast, the Critical Thinking Skills Scale used in the present study includes five parts: the Inference, Recognition of assumption, Deduction, Interpretation, and Evaluation of argument subscales. Thus, the differences between the two scales might have had an influence on the aforementioned contrasting results and require further investigation and comparison.

7. Conclusions

We found that the ICU nurses investigated in this study had only moderate-level critical thinking skills and showed only moderatelevel caring behaviors. The N2 and N3 ICU nurses showed better critical thinking skills than did the N4 nurses. The non-manager nurses had better “Interpretation” skills than did the managers, and the ICU nurses who had worked for 1-5 years or 6-9 years had better “Inference” skills than those who had worked for less than 1 year or over 10 years. The ICU nurses who were older, married, working at higher clinical levels, and had worked in clinics and ICUs for a longer time showed better caring behaviors. There was no significant correlations, meanwhile, between the critical thinking skills and caring behaviors of these ICU nurses.

For clinical practice, ICU nurses could improve their critical thinking ability by attending clinical case discussion meetings. During those meetings, nurses can share their experience and discuss their case in group discussions and it will help to enhance their critical thinking ability. In order to present caring behavior with patientcenter attitudes, nurses can arrange cross-disciplinary teamwork meetings to understand the patients’ multi-level care and needs. In nursing education, healthcare managers should seek strategies to enhance ICU nurses’ critical thinking skills and teach them specific behaviors to help them better care for ICU patients. Nursing teachers can use problem-based learning teaching tactic to let nursing students learn from clinical practice. This can cultivate and improve nursing student critical thinking as well as problem-solved ability.

8. Limitations

Because of geographical considerations, sampling methods, and selection conditions, only ICU nurses from a medical center, regional hospital, and district hospital in southern Taiwan were included in the sample. Therefore, the results of this study are relevant only to the ICU nurses who participated in this study and cannot be generalized to all ICU nurses in Taiwan.

9. Recommendations

In line with the findings of the present study, we suggest the following:

• Because caring behaviors can best be researched using qualitative research approaches, it is recommended that qualitative methods be used in similar future studies to better understand the individual differences in ICU nurses’ perceptions of caring behaviors [32] . Relatedly, further studies of the caring behaviors of ICU nurses working in private hospitals, university hospitals, and specialized units are necessary.
• In future studies, a broader variety of participants should be sampled to clarify the effects of the hospital type and level on the critical thinking skills and caring behaviors of ICU nurses.

Competing Interests

The authors declare that they have no competing interests.

• Pickett J (2009) Critical thinking a necessary factor in nursing workload. Am J Crit Care 18: 101 [ CrossRef ] [ Google Scholar ] [ PubMed ]
• Chang MJ, Chou FH, Lin CY, Lu CH, Kuo SH, et al. (2011) A preliminary study of clinical nurse critical thinking abilities: An example of a medical center in southern Taiwan. Journal of Nursing and Healthcare Research 7: 72-83
• Youssef HAM, Mansour MAM, Ayasreh IRA, Al-Mawajdeh NAA (2013) A medical-surgical nurse’s perceptions of caring behaviors among hospitals in Taif city. Life Science Journal 10:720-730 [ View ]
• Chen YC (2010) Essential professional core competencies for nurses. Hu Li Za Zhi 57: 12-17 [ Google Scholar ] [ PubMed ]
• Huang SY, Chen SL, Hu TC (2012) A study of nurses’ clinical competencies in intensive care units. VGH Nursing 29: 243-254
• Arli SK, Bakan AB, Ozturk S, Erisik E, YildirimZ, et al. (2017) Critical thinking and caring in nursing students. International Journal of Caring Sciences 10: 471-478 [ View ]
• Pai HC, Eng CJ (2013) The relationships among critical thinking disposition, caring behavior, and learning styles in student nurses. Open Journal of Nursing 3: 249-256 [ CrossRef ] [ Google Scholar ]
• Pai HC, Eng CJ, Ko HL (2013) Effect of caring behavior on disposition toward critical thinking of nursing students. J Prof Nurs 29: 423-429 [ CrossRef ] [ Google Scholar ] [ PubMed ]
• Zheng YY, Wang WJ, Wu JJ, Huang JG (1996) A preliminary report for on the construction of the Critical Thinking Scale (CTS). The Journal of the Psychological Testing 43: 213-225
• LeFevre R (2014) Critical thinking indicators (CTIs): Evidence-based version
• Chen SL, Lee WL, Chiang CH, Yuan KH (2013) Critical thinking and holistic assessment. Chang Gung Nursing 24: 24-31
• Zuriguel Pérez E, Lluch Canut MT, Falcó-Pegueroles A, Puig-Llobet M, Moreno-Arroyo C, et al. (2015) Critical thinking in nursing: Scoping review of the literature. Int J Nurs Pract 21: 820-830 [ CrossRef ] [ Google Scholar ] [ PubMed ]
• Feng RC, Chen MJ, Chen MC, Pai YC (2010) Critical thinking competence and disposition of clinical nurses in a medical center. J Nurs Res 18: 77-87 [ CrossRef ] [ Google Scholar ] [ PubMed ]
• Sarıoglu O, Usta YY, Dikmen Y, Hicks FD, Korkmaz MA, et al. (2013) Comparison of critical thinking disposition among nurses in Turkey. Health MED 7: 17-25
• Abu B, Nursalam, Merryana A, Kusnanto, Siti Nur Q, et al. (2017) Nurses’ spirituality improves caring behavior. International Journal of Evaluation and Research in Education 6:23-30 [ Google Scholar ]
• Watson MJ, Foster R (2003) The attending nurse caring model: Integrating theory, evidence and advanced caring-healing therapeutics for transforming professional practice: The Attending Nurse Caring Model. J Clin Nurs 12: 360-365 [ CrossRef ] [ Google Scholar ] [ PubMed ]
• Li YS, Yu WP, Yang BH, Liu CF (2016) A comparison of the caring behaviours of nursing students and registered nurses: Implications for nursing education. J Clin Nurs 25: 3317-3325 [ CrossRef ] [ Google Scholar ] [ PubMed ]
• Leininger M (1997) Overview of the theory of cultural care with the ethnonursing research method. Journal of Transcultural Nursing 8: 32-52 [ CrossRef ] [ Google Scholar ] [ PubMed ]
• Nelson J (2006) Madeleine Leininger’s culture care theory: The theory of culture care diversity and universality. International Journal for Human Caring 10: 50-84
• Kiliç M, Öztunç G (2015) Comparison of nursing care perceptions between patients who had surgical operation and nurses who provided care to those patients. International Journal of Caring Sciences 8: 625- 632 [ Google Scholar ]
• Lin CC (2011) A study on nurses’ professional value and caring behaviors (Unpublished master’s thesis). Available from National Digital Library of Theses and Dissertations in Taiwan
• Rafii F, Oskouie F, Nikravesh M (2007) Caring behaviors of burn nurses and the related factors. Burns 33: 299-305 [ CrossRef ] [ Google Scholar ] [ PubMed ]
• Von Essen L, Sjodén PO (2003) The importance of nurse caring behaviors as perceived by Swedish hospital patients and nursing staff. Int J Nurs Stud 40:487-497 [ CrossRef ] [ Google Scholar ] [ PubMed ]
• Yurdanur D (2016) Critical thinking competence and dispositions among critical care nurses: A descriptive study. International Journal of Caring Sciences 9: 489-495 [ Google Scholar ]
• Thayer-Bacon BJ (1993) Caring and its relationship to critical thinking. Educational Theory 43: 323-340 [ CrossRef ] [ Google Scholar ]
• Chen SY, Chang HC, Pai HC (2017) Caring behaviours directly and indirectly affect nursing students’ critical thinking. Scand J Caring Sci 32: 197-203 [ CrossRef ] [ Google Scholar ] [ PubMed ]
• Lin PF (2004) Nursing care in Taiwan: A qualitative study. The Journal of Health Science 6: 1-12 [ CrossRef ]
• Lee WL, Yang HL, Tsai SH, Tsai HY, Tsai CW, et al. (2011) Relationship between nurse caring behaviors and patient-perceived caring behaviors at regional teaching hospitals in southern Taiwan. Journal of Nursing and Healthcare Research 7: 286-294
• Lin CF, Chang YM, Yang CY, Kao CC, Lu MS, et al. (2006) Evaluating head nurses’ decision making competence from nurses’ viewpoints. New Taipei Journal of Nursing 8: 57-68
• Ma SC (2002) A study of caring behaviors perception in intensive care units from patients and nurses perspectives. (Unpublished master’s thesis). National Digital Library of Theses and Dissertations in Taiwan
• Chi CT, Ke SH, Lin SL, Sheng CC (2005) Comparison of family’s and pediatric nurse’s perception of caring behaviors and influential factors. VGH Nursing 22: 13-22 [ CrossRef ]
• Hajinezhad ME, Azodi P (2014) Nurse caring behaviors from patients’ and nurses’ perspective: A comparative study. European Online Journal of Natural and Social Sciences 3: 1010-1017
• Kaddoura M, Van‐Dyke O, Yang Q (2016) Impact of a concept map teaching approach on nursing students’ critical thinking skills. Nurs Health Sci 18: 350-354 [ CrossRef ] [ Google Scholar ] [ PubMed ]

LOGIN 

Annual Report

• Board of Directors
• Nomination Process
• Organizational Structure
• ATS Policies
• ATS Website
• MyATS Tutorial
• ATS Experts
• Press Releases

Member Newsletters

• ATS in the News
• ATS Conference News
• Embargo Policy

ATS Social Media

Breathe easy podcasts, ethics & coi, health equity, industry resources.

• Value of Collaboration
• Corporate Members
• Advertising Opportunities
• Clinical Trials
• Financial Disclosure

In Memoriam

Global health.

• International Trainee Scholarships (ITS)
• MECOR Program
• Forum of International Respiratory Societies (FIRS)
• 2019 Latin American Critical Care Conference

Peer Organizations

Careers at ats, affordable care act, ats comments and testimony, forum of international respiratory societies, tobacco control, tuberculosis, washington letter, clinical resources.

• ATS Quick Hits
• Asthma Center

Best of ATS Video Lecture Series

• Coronavirus
• Critical Care
• Disaster Related Resources
• Disease Related Resources
• Resources for Patients
• Resources for Practices
• Vaccine Resource Center

Career Development

• Resident & Medical Students
• Junior Faculty
• Training Program Directors
• ATS Reading List
• ATS Scholarships
• ATS Virtual Network

ATS Podcasts

Ats webinars, professional accreditation, pulmonary function testing (pft), calendar of events, patient resources.

• Asthma Today
• Breathing in America
• Fact Sheets: A-Z
• Fact Sheets: Topic Specific
• Patient Videos
• Other Patient Resources

Lung Disease Week

Public advisory roundtable.

• PAR Publications
• PAR at the ATS Conference

Assemblies & Sections

• Abstract Scholarships
• ATS Mentoring Programs
• ATS Official Documents
• ATS Interest Groups
• Genetics and Genomics
• Medical Education
• Terrorism and Inhalation Disasters
• Allergy, Immunology & Inflammation
• Behavioral Science and Health Services Research
• Clinical Problems
• Environmental, Occupational & Population Health
• Pulmonary Circulation
• Pulmonary Infections and Tuberculosis
• Pulmonary Rehabilitation
• Respiratory Cell & Molecular Biology
• Respiratory Structure & Function
• Sleep & Respiratory Neurobiology
• Thoracic Oncology
• Joint ATS/CHEST Clinical Practice Committee
• Clinicians Advisory
• Council of Chapter Representatives
• Documents Development and Implementation
• Drug/Device Discovery and Development
• Environmental Health Policy
• Ethics and Conflict of Interest
• Health Equity and Diversity Committee
• Health Policy
• International Conference Committee
• International Health
• Members In Transition and Training
• View more...
• Membership Benefits
• Categories & Fees
• Special Membership Programs
• Renew Your Membership
• Update Your Profile
• ATS DocMatter Community
• Respiratory Medicine Book Series
• Elizabeth A. Rich, MD Award
• Member Directory
• ATS Career Center
• Welcome Trainees
• ATS Wellness
• Thoracic Society Chapters
• Chapter Publications
• CME Sponsorship

Corporate Membership

• Assemblies and Sections

Webinar Date:  March 7, 2023

This webinar is focused on providing our perspective on the importance of macro cognition and team cognition in the decision-making process in healthcare settings, most notably the intensive care unit (ICU). The webinar includes live presentations by experts in the field followed by an interactive session from attendees. This webinar features renowned experts: Abdullah Alismail, PhD, RRT, FCCP, FAARC Associate Professor of Cardiopulmonary Sciences & Medicine Department of Cardiopulmonary Sciences, School of Allied Health Professions, Loma Linda University Health, Loma Linda, CA Lauren Blackwell, MD Assistant Professor of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine, Mount Sinai Beth Israel, New York, NY Sugeet K. Jagpal, MD Assistant Professor Division of Pulmonary, Critical Care and Sleep Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ May Lee, MD, ATSF, FCCP, FACP Clinical Associate Professor of Medicine Director, Pulmonary and Critical Care Fellowship Program Keck Medical Center of USC, Division of Pulmonary and Critical Care, Los Angeles, CA Erica Lin, MD Assistant Professor Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, CA

Jared Chiarchiaro, MD MS Associate Professor of Medicine Clinical Chief, Division of Pulmonary, Allergy, & Critical Care Medicine Oregon Health & Science University, Portland, OR

Nayla Ahmed, M.B.B.S Pulmonary & Critical Care medicine fellow at Mayo Clinic We invite your participation in this session and look forward to an insightful discussion. If you have questions about this session or have suggestions for future sessions, please contact: Avraham Cooper ATS Section on Medical Education [email protected]  

The American Thoracic Society improves global health by advancing research, patient care, and public health in pulmonary disease, critical illness, and sleep disorders. Founded in 1905 to combat TB, the ATS has grown to tackle asthma, COPD, lung cancer, sepsis, acute respiratory distress, and sleep apnea, among other diseases.

AMERICAN THORACIC SOCIETY 25 Broadway New York, NY 10004 United States of America Phone: +1 (212) 315-8600 Fax: +1 (212) 315-6498 Email: [email protected]

Privacy Statement | Term of Use | COI Conference Code of Conduct

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Critical thinking skills in intensive care and medical-surgical nurses and their explaining factors

Affiliations.

• 1 Student Research Committee, Semnan University of Medical Sciences, Semnan, Iran. Electronic address: [email protected].
• 2 Nursing Care Research Center, Semnan University of Medical Sciences, Semnan, Iran; Department of Nursing, Faculty of Nursing and Midwifery, Semnan University of Medical Sciences, Semnan, Iran. Electronic address: [email protected].
• 3 Nursing Care Research Center, Semnan University of Medical Sciences, Semnan, Iran; Department of Nursing, Faculty of Nursing and Midwifery, Semnan University of Medical Sciences, Semnan, Iran; Social Determinant of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran. Electronic address: [email protected].
• PMID: 32283476
• DOI: 10.1016/j.nepr.2020.102783

Critical thinking affects patient safety in critical situations. Nurses, in particular, intensive care unit (ICU) nurses, need to develop their critical thinking skills. The present article seeks to compare the level of critical thinking in medical-surgical and ICU nurses and investigate the factors explaining it. A cross-sectional study was conducted on 120 medical-surgical and ICU nurses (60 per group). Data were collected using the California Critical Thinking Skills Test and analyzed in SPSS-16 using independent samples t-test, ANOVA, and the regression analysis. The mean critical thinking score was 8.68 ± 2.84 in the ICU nurses and 9.12 ± 2.99 in the medical-surgical nurses. No significant differences were found between the two groups in terms of the critical thinking score and the scores of its domains. The results of the regression analysis showed that demographic variables explain only 8% of the variations in critical thinking score, as only gender explains nurses' critical thinking score. The results revealed poor critical thinking scores in the nurses working in medical-surgical wards. Investigating the reasons for the poor scores obtained and using educational strategies such as PBL, conceptual map, participation in interdisciplinary rounds, the development of clinical guidelines and participation in continuing education conferences are recommended for developing critical thinking skills in nurses.

Keywords: Critical thinking; Intensive care unit; Iran; Medical-surgical ward; Nurse.

Copyright © 2020 Elsevier Ltd. All rights reserved.

PubMed Disclaimer

Conflict of interest statement

Declaration of competing interest None.

Similar articles

• Nursing management of the critical thinking and care quality of ICU nurses: A cross-sectional study. Lee SY, Chang CY. Lee SY, et al. J Nurs Manag. 2022 Oct;30(7):2889-2896. doi: 10.1111/jonm.13591. Epub 2022 Mar 21. J Nurs Manag. 2022. PMID: 35293063
• Promoting Critical Thinking in Your Intensive Care Unit Team. Richards JB, Schwartzstein RM. Richards JB, et al. Crit Care Clin. 2022 Jan;38(1):113-127. doi: 10.1016/j.ccc.2021.08.002. Crit Care Clin. 2022. PMID: 34794626 Review.
• The perceived and experienced role of the nurse unit manager in supporting the wellbeing of intensive care unit nurses: An integrative literature review. Adams AMN, Chamberlain D, Giles TM. Adams AMN, et al. Aust Crit Care. 2019 Jul;32(4):319-329. doi: 10.1016/j.aucc.2018.06.003. Epub 2018 Aug 30. Aust Crit Care. 2019. PMID: 30174110 Review.
• Effects of reflection on clinical decision-making of intensive care unit nurses. Razieh S, Somayeh G, Fariba H. Razieh S, et al. Nurse Educ Today. 2018 Jul;66:10-14. doi: 10.1016/j.nedt.2018.03.009. Epub 2018 Mar 19. Nurse Educ Today. 2018. PMID: 29631170
• Does good critical thinking equal effective decision-making among critical care nurses? A cross-sectional survey. Ludin SM. Ludin SM. Intensive Crit Care Nurs. 2018 Feb;44:1-10. doi: 10.1016/j.iccn.2017.06.002. Epub 2017 Jun 26. Intensive Crit Care Nurs. 2018. PMID: 28663105
• Chinese version of Yoon Critical Thinking Disposition Instrument: validation using classical test theory and Rasch analysis. Au ML, Li YY, Tong LK, Wang SC, Ng WI. Au ML, et al. BMC Nurs. 2023 Oct 6;22(1):362. doi: 10.1186/s12912-023-01519-y. BMC Nurs. 2023. PMID: 37803354 Free PMC article.
• Evaluating and comparing critical thinking skills of residents of Tehran University of Medical Sciences. Mehrpour SR, Hoseini Shavoun A, Kheiltash A, Masoomi R, Nasle Seraji R. Mehrpour SR, et al. BMC Med Educ. 2023 Feb 27;23(1):133. doi: 10.1186/s12909-023-04094-7. BMC Med Educ. 2023. PMID: 36849893 Free PMC article.
• An e-Problem-Based Learning Program for Infection Control in Nursing Homes: A Quasi-Experimental Study. Choi YR, Lee YN, Kim D, Park WH, Kwon DY, Chang SO. Choi YR, et al. Int J Environ Res Public Health. 2022 Oct 16;19(20):13371. doi: 10.3390/ijerph192013371. Int J Environ Res Public Health. 2022. PMID: 36293952 Free PMC article. Clinical Trial.
• The training needs of critical care nurses: A psychometric analysis. Santana-Padilla YG, Bernat-Adell MD, Santana-Cabrera L. Santana-Padilla YG, et al. Sci Prog. 2022 Jan-Mar;105(1):368504221076823. doi: 10.1177/00368504221076823. Sci Prog. 2022. PMID: 35147050 Free PMC article.
• Psychometric properties of the critical thinking disposition assessment test amongst medical students in China: a cross-sectional study. Cui L, Zhu Y, Qu J, Tie L, Wang Z, Qu B. Cui L, et al. BMC Med Educ. 2021 Jan 6;21(1):10. doi: 10.1186/s12909-020-02437-2. BMC Med Educ. 2021. PMID: 33407421 Free PMC article.
• Search in MeSH

LinkOut - more resources

Full text sources.

• Elsevier Science
• MedlinePlus Health Information
• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

• ABOUT US About the Journal About the Publisher Editorial Board FAQs Journal Metrics --> Open Access Policy Quick Track Option -->
• ETHICAL GUIDELINES Allegations From whistleblowers Authorship Conflict of Interest Fabricating and Stating False Information Plagiarism Prevention Post Publication Discussions and Corrections Publishing Ethics Research Misconduct
• FOR EDITORS & REVIEWERS Editorial Management Editorial Policies Ensuring Content Integrity Ethical Guidelines for New Editors Guest Editor Guidelines Peer Review Workflow Publication Process Guidelines for Peer Reviewers
• FOR GUEST EDITORS Guidelines for Guest Editors
• FOR AUTHORS Archiving Policies Article Processing Charges Author Benefits Bentham Manuscript Processing System Corporate Membership Instructions for Authors Manuscript Transfer Facility Special Fee Waivers and Discounts
• Submit Manuscript
• MARKETING OPPORTUNITIES Advertise With Us Kudos Advertising Policy
• BECOME A PART Submit Abstract Online Submit Issue Proposal Become an Editorial Member Become a Reviewer Become a Section Editor Become an Executive Guest Editor Become a Member

Application of Evidence-based Practice in Intensive and Critical Care Nursing

E-Mail Address of Dr. Evelina Šabanė

[email protected]

E-Mail Address of Dr. Renata Vimantaitė

E-mail address of dr. povilas jakuška, downloads 11,803.

• Last 6 Months 11,803
• Last 12 Months 11,803

Background:

Evidence-based solutions are the main point of high-quality and patient-centered care. Studies analyzing the implementation of evidence-based nursing are an integral part of quality improvement. The study aims to analyze the application of evidence-based practice in intensive and critical care nursing.

This research was performed in the Hospital of Lithuanian University of Health Sciences Kaunas Clinics in intensive care units (ICU) departments in 2019. 202 critical care nurses participated in this survey (response rate 94.3%)—method of research – anonymous questionnaire. Research object – implementing evidence-based nursing practice among nurses working in intensive care units. Research instrument – questionnaire composed by McEvoy et al. (2010) [1]. Statistical analysis was performed with SPSS 24.0 and MS Excel 2016 software. Descriptive statistics were used to analyse our sample and presented in percentages. Quantitive data are presented as mean with standard deviation (m±SD). Among exploratory groups, a p-value <0.05 was considered statistically significant.

Nurses with higher university education claim to know evidence-based nursing terminology better with a statistical significance (p= 0.001) and to have higher self-confidence in evidence application (p= 0.001) compared to nurses with professional or higher non-university education. It has been determined that age directly correlates with the implementation of evidence-based nursing: compared to their older colleagues, younger nurses have statistically significantly more knowledge (p= 0.001), skills (p= 0.012) and self-confidence when applying evidence (p= 0.001) as well as a more positive approach to evidence-based nursing (p= 0.041). Nurses whose total work experience exceeds 20 years have statistically significantly less knowledge of evidence-based practice terminology than nurses whose work experience is 10 years or less (p= 0.001). It has been determined that Intensive and Critical Care Nurses (ICU Nurses) with 10 years or less experience under their belt know the terms related to evidence-based nursing statistically significantly better (p= 0.001) and applies evidence-based knowledge in clinical practice more often, compared to nurses who have worked in the ICU for longer, e.g. , 11-20 years or more than 20 years (p= 0.006). Compared to the nurses working in the ICU for 11-20 years, 10 years or less, those working for more than 20 years encounter statistically significantly more problems when applying an evidence-based approach in clinical practice (p=0.017).

Conclusion:

Younger nurses with higher education and less general work experience tend to have more knowledge and a more positive approach to evidence-based nursing. Problems with an evidence-based approach in clinical practice more often occur in nurses who have worked in the ICU for more than 20 years. Most of the nurses who participated in the study claimed that the lack of time was one of the key problems when practicing evidence-based nursing.

1. INTRODUCTION

In light of the changes in the health care system and the increasing expectations of society, the attitude towards nursing science and the limits of nursing competencies also change, increasing autonomy and advancement of the science of nursing [ 2 ]. Scientists return to the holistic approach to human health, evidence-based clinical solutions and treatment and nursing methods more and more often [ 3 ]. Evidence-based nursing is a fair application of an evidence-based approach in clinical practice and making decisions that ensure the highest quality of patient care [ 4 ]. Evidence-based practice forms a system of clinical solutions to problems and allows nurses to improve continuously and seek only the best professional results [ 5 , 6 ]. Efficient and high-quality care and patient safety are the most important aspects that are ensured by applying evidence-based nursing practice [ 7 ].

ICU Nurses make many clinical decisions in their work. According to the researchers, ICU nurses must make clinical decisions every five seconds [ 8 ]. Thus, it is especially important to base those decisions on scientific evidence. Systematic application of evidence in intensive and critical care has undisputable benefits both to the nurses and to the patients. Nurses get a boost in work satisfaction, gain autonomy and have higher self-confidence in making decisions directly related to their patients' health conditions [ 9 ]. Meanwhile, the patients and their relatives know that all performed manipulations are safe and efficient, as proven by scientific studies, their hospitalization is shorter, mistakes are avoided, and the individual wishes and needs of patients are taken into account [ 10 , 11 ]. Evidence-based nursing practice significantly contributes to avoiding common complications in ICU, such as respiratory tract infection and sepsis [ 12 - 14 ].

When introducing evidence-based nursing in an institution, the preparedness and attitude of employees are very important. Studies analyzing the knowledge, predisposition and skills of nurses and the obstacles they face in implementing advanced nursing practice are an important and integral part of the healthcare service improvement chain [ 15 , 16 ]. Analysis of organizational barriers to applying evidence-based practice is also important [ 17 ]. Courses, simulations and seminars initiated by the workplace notably contribute to nurses' capability to apply evidence-based practice [ 18 ]. However, not all healthcare professionals apply the evidence-based practice. There are various reasons for that. For example, nurses are not interested in scientific innovations; they value work experience based more on traditions due to tight working schedules, willingness to learn, lack of knowledge or other factors [ 19 ]. Timely correction of obstacles to applying evidence-based practice may significantly improve the quality of healthcare services [ 20 ]. Aspects related to evidence-based nursing are not widely researched in Lithuania, unlike in other countries worldwide. This is why a study was carried out to analyze the application of evidence-based practice in intensive and critical care nursing.

2. MATERIALS AND METHODS

The study was carried out at the ICU of Kaunas Clinics of the Lithuanian University of Health Sciences Hospital in 2019. The Center of Bioethics of the Lithuanian University of Health Sciences issued a permit to carry out the study after the presentation of the annotation and the research instrument. Targeted sampling was applied. The respondents were the nurses working at the ICU of Kaunas Clinics of the Lithuanian University of Health Sciences Hospital. A total of 202 nurses were questioned, with a response rate of 94.3%. Research method: an anonymous questionnaire-based survey. Research object: applying the evidence-based practice in intensive and critical care nursing. A total of 20 questionnaire examples were given to the ICU Nurses before the study. The pilot study results revealed that the questions given in the questionnaire were understandable. The nurses gave no comments, and thus no corrections were made. The research instrument was the questionnaire prepared by McEvoy et al. (2010) [ 1 ]. Cronbach’s alpha of the questionnaire is 0,954. It shows reliability and high internal consistency. The questionnaire was used with the permission of the authors. The questions could be categorized as follows:

1. Demographic questions determined the respondents' age, gender, education, professional experience, work experience at the current institution and work positions.

2. The respondents had to rate evidence-based nursing-related statements and terms from 1 to 5 based on the Likert scale, where 1 meant total disagreement and 5 meant total agreement. Factor analysis helped to sort the 58 statements into 5 areas: importance, obstacles, terminology, practice and self-confidence.

2.1. Statistical Data Analysis

Statistical data analysis was conducted using the SPSS 24.0 (Statistical Package for the Social Sciences) software and MC Excel 2016. Descriptive statistics, i.e. , absolute (n) and percentage (%) values, were applied to assess the distribution of the analyzed aspects in the sample. The quantitative data were presented as arithmetic means (m) with standard deviation (SD). The normalcy of the probability distribution of quantitative variables was assessed using the Kolmogorov–Smirnov test. The ANOVA test was used, the Fisher criterion (F) was calculated, and the Bonferroni adjustment was employed to compare the mean values of parametric variables of more than two independent samples. Tables of related aspects were made to assess the connections between aspects. The dependence of aspects was determined using the chi-square (χ2) test, and the pair comparisons were carried out via the z-test and Bonferroni adjustment. The Pearson correlation coefficient (r) was calculated to assess the strength of the aspect connection satisfying the normalcy assumption (r). In the case of 0<|r|≤0.3, the values were slightly dependent, in the case of 0.3<|r|≤0.8, the values were averagely dependent, and in the case of 0.8<|r|≤1, the values were strongly dependent [ 21 ]. The correlation coefficient was positive when a value increased with another value and negative when a value decreased with another value. Linear regression was used to assess variable dependence when the significance level was p<0.05, the difference of aspects in respondent groups was deemed statistically significant and when p<0.001, it was deemed highly statistically significant.

3.1. Knowledge and Attitude of Icu Nurses in Terms of Evidence-based Nursing

The study included comparing evidence-based nursing application areas based on the respondents' education. Nurses with higher university education claimed to know evidence-based nursing terminology better with a statistical significance than nurses with professional or higher non-university education. The research data also showed that nurses with higher university education had statistically significantly more self-confidence when applying scientific evidence than nurses with professional or higher non-university education. Detailed scores of evidence-based nursing application areas with standard deviations and their comparison are given in Table 1 below.

Linear regression was done to analyze the dependency of evidence-based nursing application areas on the age of the respondents. The results showed that all areas of evidence-based nursing application were statistically significantly dependent on the age of the respondents. Negative β coefficients in all four areas meant that as the age of the respondents increased, their agreement with the statements reflecting the analyzed areas decreased. Older nurses deemed evidence-based nursing to be less important than the younger ones. The terminology knowledge of older respondents was also poorer than that of their younger colleagues. Also, older nurses exhibited less evidence-based nursing-related practice and lower self-confidence (Table 2 ).

The application of evidence-based nursing in the ICU based on the work experience of the respondents was analyzed. The way the nurses with work experience in the ICU assessed evidence-based nursing areas was compared. It was determined that nurses who have worked in the ICU for 10 years or less knew the terminology related to evidence-based nursing statistically significantly better. Also, these nurses statistically significantly more often based their decisions in clinical practice on scientific evidence, compared to nurses who have worked in the ICU for longer, e.g. , 11-20 years or over 20 years. Compared to respondents with over 20 years of work experience in the ICU, nurses with 10 years or less experience had statistically significantly high self-confidence in their knowledge and skills to apply evidence-based practice in nursing. Detailed information on the evidence-based nursing application area scores and standard deviations and their comparison with the work experience of the ICU Nurses are presented in Table 3 .

3.2. Obstacles That ICU Nurses Face When Applying Evidence-based Nursing

The comparison of the obstacles to evidence-based nursing based on the work experience of the nurses in the ICU was carried out. The maximum available score was 35. A statistically significant difference was found: compared to respondents who have worked for 11-20 years, 10 years or less, ICU Nurses with over 20 years of experience faced many obstacles when applying an evidence-based nursing approach. Thus, the longer the nurses work in the ICU, the more obstacles they face when applying an evidence-based nursing approach. Detailed information about the mean values of the scores and their comparison based on the work experience of the respondents in their current workplace is presented in Fig. ( 1 ).

3.3. Peculiarities Of Evidence-based Practice In Intensive And Critical Care Units Of Different Medical Fields

The study analyzed the peculiarities of applying the evidence-based practice in intensive and critical care units of different medical fields. It was determined that the ICU Nurses at the Department of Obstetrics and Gynecology considered evidence-based nursing to be less important than the Nurses working at the Central Resuscitation Department and the Neurosurgery Department. The difference was statistically significant. The importance of applying evidence in their work was rated highest by the ICU Nurses at the Neurosurgery Department and lowest by the ICU Nurses at the Department of Obstetrics and Gynecology. Detailed information about the importance of evidence-based nursing scores by the respondents from various departments and their comparison are presented in Fig. ( 2 ).

The study assessed the self-confidence of nurses when applying the evidence-based nursing approach and compared it among different departments. Self-confidence in evidence-based nursing and making evidence-based clinical decisions revealed statistically significant differences among the ICUs of the Obstetrics and Gynecology Department, Cardiology Department, Neurosurgery Department and Central Resuscitation Department. Compared to the nurses in other departments, the ICU Nurses in the Obstetrics and Gynecology Department had lower self-confidence when applying the evidence-based nursing approach (Fig. 3 ).

The study revealed that nurses applying the evidence-based approach faced certain barriers. The obstacles encountered in evidence-based nursing in the ICU of different medical fields were compared. The results revealed that the majority of problems in evidence-based nursing were experienced by the ICU Nurses of the Obstetrics and Gynecology Department. The Newborn ICU Nurses encountered the least problems. The difference was deemed statistically significant. Detailed information about the comparison of problems in evidence-based nursing based on the ICU profile is presented in Fig. ( 4 ).

4. DISCUSSION

The study analyzed the implementation of evidence-based nursing by the ICU Nurses at Kaunas Clinics in different aspects. The comparison of evidence-based nursing-related knowledge and attitude, the implementation of the evidence-based approach and self-confidence in its implementation was carried out in terms of the education of the respondents. The results revealed that nurses with higher university education had more knowledge and self-confidence when applying scientific evidence in clinical practice. Bovino et al. presented similar findings: according to their research of 2017, nurses with higher university education (bachelor’s or master’s degree) used evidence in their clinical practice more often and had higher self-confidence in their actions, compared to nurses with a lower level of education [ 22 ]. According to the study of Balakas et al. (2016), the implementation of evidence-based nursing was directly related to the education of the nurses, i.e. , those with master’s or doctor’s degrees showed better results in formulating clinical questions, searching for the most reliable evidence and applying it in clinical practice [ 23 ]. Majid et al. research showed that nurses with higher education and participating in evidence-based training had fewer barriers to applying evidence-based practice [ 19 ]. According to Li et al. , nurses with higher education and positions were more competent in applying evidence-based practice [ 24 ].

The age of the nurses also influenced the application of the evidence-based nursing approach. The study revealed that older nurses faced more obstacles when implementing evidence-based nursing. They had less knowledge and skills related to applying evidence in nursing. According to the study of Warren et al. (2016), younger nurses (22-29 years old) were statistically significantly better prepared to base their actions on evidence in clinical practice. Also, a statistically significantly higher number of younger nurses had a positive attitude toward evidence-based nursing and supported its importance [ 25 ].

Based on the opinion of many researchers, critical thinking is a key skill for ICU Nurses in making urgent clinical decisions, and the latter is integral to evidence-based practice. Ludin (2018) carried out a study with 113 ICU Nurses. It was determined that age and work experience in the ICU greatly affected the nurses' critical thinking and decision-making based on scientific evidence, e.g. , older nurses with higher work experience had statistically significantly better skills in critical thinking and making clinical decisions [ 8 ]. Meanwhile, the results of this study were the opposite: the clinical decisions made by younger nurses with less work experience were more often based on scientific evidence. The research conducted by Alqahtani and co-authors (2022) showed that nurses working in the intensive care unit and emergency department have more knowledge about evidence-based practice than nurses from general units. Their research also concluded that nurses who participated in evidence-based practice courses had better attitudes, knowledge, and leadership skills than nurses who did not participate [ 26 ].

The attitude of the nurses is very important in an evidence-based approach in clinical practice. This study revealed that older nurses deemed evidence-based nursing less important than younger nurses. Nurses with higher education showed a more positive attitude to the application of scientific evidence in nursing: the statement ‘I have had enough of evidence-based nursing’ gained the agreement of 34.2% of nurses with professional education, 11.5% of nurses with higher non-university education, and 14.9% of nurses with higher university education. The difference is statistically significant. Based on the study by Swiss researchers Pereira et al. (2018), nurses with a more positive attitude towards evidence-based nursing usually base their clinical decisions on evidence statistically significantly more often [ 27 ]. The same trend was seen in this study: younger nurses, who, as mentioned previously, deemed evidence-based practice more important than older nurses, based their clinical decisions on scientific evidence statistically significantly more often. 507 nurses participated in a study by Degu and co-authors (2022). 55% of participants had a positive attitude toward evidence-based practice. Research showed that higher-education nurses had more knowledge about evidence-based practice, which led to a more positive attitude to evidence-based practice [ 28 ].

The research data revealed that certain barriers existed when implementing evidence-based nursing. Stavor et al. (2017) indicated that the main obstacles to applying an evidence-based approach in nursing were the avoidance of change, negative attitude and lack of time [ 29 ]. According to a study by Chinese scientists (2020), the lack of knowledge was the main problem in applying evidence-based nursing [ 30 ]. O’Connell et al. (2018) distinguished the two barriers: insufficient knowledge and the lack of cooperation between the nurses and the doctors [ 31 ]. In this study, more than half of the respondents (55.4%) said that the lack of time was one of the largest obstacles to implementing evidence-based nursing in clinical practice. The study also revealed that compared to younger nurses and nurses with less experience in intensive and critical care, older nurses and nurses with more work experience in the ICU encountered more problems when applying the evidence-based approach in nursing. Al-Lenjawi et al. conducted a study with 278 nurses from ICU. The research revealed that the main barriers to applying evidence-based practice are lack of time and support from colleagues, inability to understand statistics, and negative attitude to evidence-based practice [ 32 ]. The mentorship program is one method to encourage nurses to use evidence-based practice. Nurses gained more knowledge and a more positive attitude; there were fewer obstacles to applying evidence-based practice after the mentorship program [ 33 ]. Following Patelarou et al. , evidence-based practice training strongly contributes to more effective healthcare and should be the priority in establishing nursing education programs [ 34 ]. The benefits of evidence-based practice training were emphasized by Ruppel et al. based on the data of their study – nurses with a positive attitude towards evidence-based practice still indicated that training is necessary due to a lack of knowledge [ 35 ].

Thus, critical thinking, a holistic approach to a patient’s health condition, and the ability to work and plan patient care in a multidisciplinary team based on the most trustworthy scientific evidence for each individual case should be the daily duties and responsibilities of each nurse. Studies analyzing the implementation of evidence-based practice are important in attaining the best results in nursing and its practice [ 36 ]. Most of this study's results comply with the studies of foreign researchers. Younger nurses with higher education have better knowledge of applying evidence-based practice in nursing and have a more positive attitude toward it. Nurses with a lower level of education, and in this study, older nurses encounter more problems when applying evidence in clinical practice. The main obstacles to implementing evidence-based nursing are the lack of time, resources and knowledge.

1. The knowledge and attitude of the ICU Nurses related to evidence-based nursing and the implementation of this approach depend on such factors as education, age and work experience. Younger nurses with higher education and less work experience in the ICU tend to have more knowledge of evidence-based nursing and a more positive attitude toward it.

2. Older nurses and nurses whose work experience in the ICU is over 20 years encounter problems when applying scientific evidence in clinical practice more often. Most of the respondents believe the lack of time is one of the major obstacles to implementing evidence-based nursing in clinical practice.

3. The comparison of the peculiarities of employing evidence-based nursing in the ICUs of different medical fields revealed that the ICU Nurses of the Obstetrics and Gynecology Department deemed evidence-based nursing to be less important and thus had lower self-confidence and encountered more problems when applying an evidence-based approach in nursing.

LIST OF ABBREVIATIONS

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The Center of Bioethics of the Lithuanian University of Health Sciences issued a permit to carry out the study after the presentation of the annotation and the research instrument (the approval number BEC-ISP(M)-14). Participants submitted informed consent.

HUMAN AND ANIMAL RIGHTS

No animals were used in this research. All procedures performed in studies involving human participants were per the ethical standards of institutional and/or research committees and with the 1975 Declaration of Helsinki, as revised in 2013.

CONSENT FOR PUBLICATION

Informed consent was obtained from all participants.

AVAILABILITY OF DATA AND MATERIALS

Not applicable.

This study was funded by Lithuanian University of Health Sciences Kaunas Clinics Department of Cardiac, Thoracic and Vascular Surgery.

CONFLICT OF INTEREST

The authors declare no conflicts of interest, financial or otherwise.

ACKNOWLEDGEMENTS

We would like to thank the ICU Nurses of Kaunas Clinics of the Lithuanian University of Health Sciences Hospital, who have consented to participate in the study.

Authors & Information

Affiliations, information, published in.

Article Information

Article history.

Citations & Metrics

Export citation.

Select the format you want to export the citation of this publication.

Citation information is sourced from Crossref Cited-by service.

Article Usage (Last 30 Days)

Article usage (demographic), copyright & license, copyright and license, © 2022 šabanė .et al.

Open-Access License: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode . This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Address correspondence to this author at the Department of Nursing, Lithuanian University of Health Sciences, Medical Academy, Kaunas, ; E-mail: [email protected]

Share article link

Copying failed.

Share on social media

Simulation Scenarios

A simulation scenario is an artificial representation of a real-world event to achieve educational goals through experiential learning.

A basic collection of scenarios is provided below. This is by no means a complete resource, but the start of something we can grow as a Faculty.

Make a submission

We hope to curate rather than create this resource, as we know there is so much phenomenal simulation occurring up and down the UK already, with excellent resources already in existence so please contact us and send in your scenarios .

CCOT Assessing Patient for Discharge

Paediatric status epilepticus, fire safety - burns bundle: fire simulation 1, fire safety - burns bundle: fire simulation 2, maternal cardiac arrest, upper gi haemorrhage, patient transfer to ct, dislodged ett in a proned patient, covid ards proning, overdose – calcium channel blocker, type a aortic dissection pre transfer, beta blocker overdose, migrated ett on transfer, bradycardia – digoxin toxicity, bleeding post cardiac surgery, accidental extubation, exacerbation of asthma, hyperkalaemia, septic shock and cardiac arrest, subarachnoid haemorrhage re-bleed, tension pneumothorax, blocked tracheostomy, instructional videos.

These videos will help you simulate ventilator behaviour and bleeding into drains (required for some of the scenarios). 

Do you have simulation resources? If so and you would like them featured on the FICM website, please get in touch.

Related content

Getting started in Simulation

• General Nursing
• Nursing Specialties
• Nursing Students
• United States Nursing
• World Nursing
• Boards of Nursing
• Breakroom / Clubs
• Nurse Q&A
• Student Q&A
• Fastest BSN
• Most Affordable BSN
• Fastest MSN
• Most Affordable MSN
• Best RN to BSN
• Fastest RN to BSN
• Most Affordable RN to BSN
• Best LPN/LVN
• Fastest LPN/LVN
• Most Affordable LPN/LVN
• Fastest DNP
• Most Affordable DNP
• Medical Assistant
• Best Online Medical Assistant
• Best Accelerated Medical Assistant
• Most Affordable Medical Assistant
• Nurse Practitioner
• Pediatric NP
• Neonatal NP
• Oncology NP
• Acute Care NP
• Aesthetic NP
• Women's Health NP
• Adult-Gerontology NP
• Emergency NP
• Best RN to NP
• Psychiatric-Mental Health NP
• RN Specialties
• Best RN Jobs and Salaries
• Aesthetic Nurse
• Nursing Informatics
• Nurse Case Manager
• Forensic Nurse
• Labor and Delivery Nurse
• Psychiatric Nurse
• Pediatric Nurse
• Travel Nurse
• Telemetry Nurse
• Dermatology Nurse
• Best NP Jobs and Salaries
• Family NP (FNP)
• Orthopedic NP
• Psychiatric-Mental Health NP (PMHNP)
• Nurse Educator
• Nurse Administrator
• Certified Nurse Midwife (CNM)
• Clinical Nurse Specialist (CNS)
• Certified Registered Nurse Anesthetist (CRNA)
• Best Free Online NCLEX-RN Study Guide
• The Nursing Process
• Question Leveling
• NCLEX-RN Question Identification
• Expert NCLEX-RN Test-Taking Strategies
• Best Scrubs for Nurses
• Best Shoes for Nurses
• Best Stethoscopes for Nurses
• Best Gifts for Nurses
• Undergraduate
• How to Become an LPN/LVN
• How to Earn an ADN
• Differences Between ADN, ASN, AAS
• How to Earn a BSN
• Best MSN Concentrations
• Is an MSN Worth It?
• How to Earn a DNP
• MSN vs. DNP

How to develop ICU critical thinking skills and move away from being "task" focused

Specialties MICU

Published Jun 27, 2014

I am having problems with being "task" focused while trying to develop ICU critical thinking and clinical skills. I have been in the SICU for 4 months and still struggling. At first I was told that I was struggling with completing task and using critical thinking skills and now I am being told that I am "task" focused; lack knowledge and do not use critical thinking skills.

I have been trying to figure out where I am going wrong without having any constructive criticism or examples whereby I am exhibiting these behaviors. What I have been doing is reading the Pass CCRN book that has been mention so much on this site and reviewing disease processes; interventions and outcome to improve my knowledge base in hopes of improving my critical thinking and clinical skills. Being "task" focus I think is due to my ER background and that is why I wanted to be in the ICU because I have always thought I lacked critical thinking and associated this with lack of knowledge that in ED our main goal is to stabilize; treat and street our patients but in ICU I have observed that it's about understanding the patho and what am I going to do to keep this pt stable and fix the reason why they are in the ICU.

I have PCU experience and just realizing I did not utilize my time to help my transition into ICU and now I am playing catch up with pressure of being moved out of ICU and I really need some advice as to how to show that I am improving and capable of becoming a competent and safe ICU nurse. I don't want to go back to PCU because I don't feel like this will help me because I already have been in this setting. I just feel like I need more time but not sure how to improve faster and get up to speed because I am so behind as I have been told on my unit. I feel very overwhelmed when I am at work because I do focus on the "task" that I need to complete like : I need to assess my pt; I need to chart my assessment; I need to pass my meds; I need to change IV tubing; dressing changes; bathe my patient; chart VS: chart my q2's. I find that I run out of time and always charting 30-45 min after my shift is over which is viewed bad in my unit because of overtime.

I find myself not being able to grasp the whole picture as to why my patient is here and why am I doing these "task." I also feel like my time management is lacking and that I am not always so organize even though I use a brain sheet to help keep me on track. I have tried different ways to organize my time but nothing seems to work. For example; I get report; look at my orders then assess my pt; try to chart; bathe pt; give meds then when I look up it's about 11 and I don't even really have the full picture of my pt; have not read in detail the MD not or what has been written on my pt and then am not able to communicate when the CN comes to ask about my pt. I feel like I am just running the whole shift and not really know what's going on with my pt. I have asked some co-workers how they plan and in theory I have the same plan but I am not executing the plan that I have in my head when I start my shift.

Please give me some advice no matter how simple or harsh as I am trying to expedite and get to where I need to be so I can stay in ICU. Any suggestions will be helpful with time management; organization; planning my day; how to have the whole picture and move away from being "task" focused.

• + Add a Comment

Da_Milk_of_Amnesia, MSN

Critical thinking skills can be taught or learned from a book. It's something that comes with time and experience. (this is just my opinion) I think critical thinking comes from a understanding of basic and some advanced physiology, pharmacology etc. But a lot of this is just from experience.

Here's something to think thru that I had to go thru and since I had no idea what was going on I learned it and never forgot it.

For instance, If you have someone with a blown mitral valve. What do you want to do?

Well think about it. What's wrong, first of all? Blown segment - every single heart beat is shooting blood back into the plum. veins and the patients lungs are literally filling up. You need to get more Blood moving forward right.

So what would you give? The answer: Vasodilators and eventually an IABP

Why? You need to decrease the after load, blood is going to go in the path of least resistance. If you decrease the resistance in front of it, you'll make it want to preferentially go that way.

- Idk if that help, but thats one way to go thru things. There are hundreds of ways to skin a cat and you'll eventually learn one of the ways. There are other things you can do as far as time management goes. I used to pull out all my meds at the beginning of the shift (if i had a whole lot to give) we had little places where we could hide them in the room so we did. I just made sure to label and double and triple check against my MAR. There are many other little tricks that you can do to cut down on time. You will learn them as you go, I know you can give meds up to 30 to 1 hr before right? If i could I would always give stuff early but within reason. I would also chart things that i knew were not going to change, like if the patient had a swan, I know my temps are all going to come from that so i'd go down the line and click whatever box it was. IT's little things like that, that will help you save some time. Some people may disagree with me or not. Take what you want from it and use it if you like it. The bottom line is that you're not going to learn it all, no one can 'teach' it to you and you can't learn it from a book. You either got it or you don't and right now you don't. You're going to have to work your ass off, so get moving.

Esme12, ASN, BSN, RN

1 Article; 20,908 Posts

I get frustrated by these statements when they cannot give an improvement plan and examples of what they feel you are doing wrong.

It takes time to develop that all encompassing ICU focus. Four months isn't long enough. You are very task focused at first it's survival. It is a learned process and takes time.

My suggestions. Go home after work or on break (If you get one) look up disease processes. Start to make the connections. Give me an example...and I will try to walk you through. When I started in ICU...I would come in early (after discussing it with my manager) not clock in and look at the patient charts. I would read the MD/consult H/P and progress notes of the patient I will be getting or the patient I had the day before. With all the fear of HIPAA (which is an unjustified fear) they "need to know" has been interpreted as ....if you are not actively caring for the patient don't go in the record...which is sad as that is where you learn.

Multitask when getting report. I like to have the computer open to click around in as I get report. This has annoyed some nurses...they feel I am not paying attention...but I can repeat verbatim every word they have said. As I check orders I glance at the progress notes for the previous day. When I give meds I think of why I am giving the med and how it effects the patient.

You are stressing yourself. I am willing to bet you already do this but don't know how to verbalize it to their satisfaction.

Thank you for your advice Da_Milk_of_Amnesia. I agree with your post and I have been doing just what you have mentioned over the last week. I am in the process of finding ways to improve my knowledge to help improve my critical thinking skills with reviewing disease process and management. I Just think it has taken me a long while to try to figure this out on my own and my unit has the opinion that I am "behind the times" as it was stated. In my opinion, I just think I need more time to develop and from reading different posts it seems reasonable that 6 mths - 1 yr to get my groove and that it will take another yr to be more comfortable. I guess with being on the unit for 7 mths (3 months of orientation and 4 months on my own) I have not proved myself to the unit but I have been working to expedite the learning curve to help facilitate being a better ICU nurse. It has been tough because no one told me what I was doing so I had to figure things out on my own and develop my own plan. Please don't get me wrong as I am not trying to make excuses and I know that it is my responsibility to facilitate my own learning and take charge it was just confusing to think I was performing well and then being told otherwise without having any specifics.

Thank you Esme12 for your advice. I have in the past went in early to look at my assignment but stopped because the assignments were not always done and at the time I didn't realize that I could have been violating HIPPA so I will speak to my manager and get permission because now that I realize my mistakes and understand that having the time to read over the pt's H&P and notes from the MD's and ancillary staff would help me to focus on the whole picture until I get the hang of organizing my time to incorporate this without having to come in early. Also since I didn't fully understand the importance of looking at the whole picture to understand the management of the pt and started being "task" focused and not realizing and understanding the "why" I was doing the "task." In addition to this, I would be frustrated that I could not articulate to the CN or when giving report which I was all over the place because I was so scattered brain and would have my co-workers and CN be annoyed with me.

You are absolutely correct as I was in "survival" mode and reverted back to my ED ways of being "task" focused and not taking the time to breathe and relax and think about the whole picture as to why the pt was here and what would I expect the management to be in order to fix the pt and understand why I was doing these "task." I just think that it has taken me longer than my counterparts who have gotten their groove early than I did but in my opinion they had more direction and help than I did. Please don't take that last statement like I am making excuses because I know that it's my responsibility to facilitate and take charge of my learning which is what I have done over the last week now that I finally see where I was lacking and have been reviewing disease processes and what to expect the management and complications so I am hoping to bridge the learning curve in the ICU and improve my critical thinking and knowledge and keep working on managing my time while focusing on the whole picture.

Your statement about "stressing out" is absolutely correct because I was in this mode for about 3 weeks trying to figure out what I was doing wrong and frustrated about not having any feedback as well. I also could not focus because of the fear of being asked to leave the unit however after talking to friends I was able to communicate what I was doing, how I didn't have the time to see the whole picture and was behind because I was just trying to do "task" and not being able to communicate what was going on with the pt or the POC and how I would get frustrated and didn't have a plan and that's how it came about starting over like a new grad and reviewing disease processes and looking at the whole picture and taking it a step further by seeing things as a provider would as some of my friends are in NP school and explained to me how they had to make this same transition from RN to provider. I realized my previous RN experience I didn't look at the whole picture for example in the ED I just focused on the primary issue and understand that one issue and knew the "task" or management of that pt. In the PCU, I must admit that I didn't think as a provider but I think because I was able to make the transition and take care of the pt's I didn't have the same pressure like I am experiencing in the ICU.

Now that I have stopped stressing and being fearful of being asked to leave. I am now focusing on my plan with looking at the whole picture like you mentioned and hopefully I will bridge the "you're way behind" that has been mentioned to me and will show great improvement on my unit.

ilikesharpthings

Ruby Vee, BSN

17 Articles; 14,031 Posts

Esme is absolutely right about studying in your free time. You absolutely cannot learn to put it all together in a complicated environment like the ICU without spending some time studying on your own. The good news is, as you become more experienced and learn more, you have to spend less and less time studying at home. Or on your break.

As far as learning critical thinking skills -- you should be understanding the rationale for every intervention and every medication you give. It's not enough to turn your patient every two hours -- you have to understand WHY you're turning your patient. WHY are you giving that Coumadin through the PEG tube when the patient is also on a Heparin drip? If you don't understand why you're doing something, either look it up or ask. Read the H & P -- they'll explain a lot of what is going on. Read the consulting service's notes. Make sure you understand your lab values. It's not enough to know that the INR is 6.7 unless you can relate it to the cherry red urine and the rapidly dropping hemoglobin. It takes more time and effort at first to understand the whys, but the advantage is that you start to be able to put it all together a lot faster.

calivianya, BSN, RN

2,418 Posts

Ruby Vee said basically what I was going to say - you need to ask why about absolutely everything you are doing and giving, and why the physicians write the orders that they do, and get your coworkers involved in your thought processes! Use your coworkers as resources and talk over patient care with them. Having someone double-check your thinking will teach you a lot about how to critically think in the first place, and will point out the things you are missing.

A good example happened just the other day for me - my coworker had a patient with a persistently high heart rate, no fever, seemed adequately hydrated (was making great urine), her pain was under control, etc. I was sharing a perch with this coworker so I ended up being very involved in caring for his patient. We had done labs, but no mag level. He had called multiple times about her heart rate and we did an EKG, which the physician can read over the intranet. The physician ordered 2g magnesium sulfate IV and neither of us could figure out exactly why, so we looked up magnesium on Lexicomp. It's not like we didn't know what it was or what it did, but odds are the physician was giving it for a reason, right? Maybe there was a reason we didn't know about. It said nothing about using mag for high heart rates in our drug reference. He refused to give it without a mag level from the lab, and so we drew more labs. The mag level did indeed come back low, and he hung the mag.

We were still wondering how the physician had made the jump to order mag just based on an elevated heart rate without a mag level when a coworker was walking down the paper copy of the patient's EKG to us. We mentioned it to her the whole confusion over the mag, and she just out and said, "Well, this EKG says the patient has a really long QTC interval." Prolonged QTC -> risk for Torsades -> Torsades is treated with mag, so we came back to the conclusion that the physician must have looked at the EKG and thought the patient's mag might be low because of the prolonged QTC. Or maybe she didn't assume the mag was low since other things can cause a prolonged QTC interval and just wanted to reduce the risk of the patient going into torsades because her QTC was so long. Either way, even with two heads put together we were still barking up the wrong tree when it came to figuring out what was going on. The two of us were fixated on the patient's heart rate when it was the characteristics of the rhythm we should have been looking at. Sometimes critical thinking really happens best in groups. Besides, the side benefit of critically thinking in groups is that your coworkers see that you are working on your critical thinking... which can trickle back to your manager and show that you are really focused on fixing your problems... it's a win-win situation.

marienm, RN, CCRN

I'm a new nurse, just about to finish my 1st year on an ICU that that cares for burn patients primarily. Our hospital doesn't have step-down units, so we also have SD patients on our unit...and sometimes we also have floor patients who just haven't been moved yet. I work nights (8s and 12s). I'm still struggling with time management too!

I think it's problematic that people are telling you that your critical thinking skills aren't up to par but are not giving you any specific examples. Can you think of specific cases where you missed a change in patient condition because you were so focused on getting through your "task list?" Or do they (whoever they are) mean that you're not using your critical thinking to organize your work? For example, getting a q2hour PTT drawn on time is probably more important than doing mouth care exactly every 2 hours, even though the mouth care is important and does need to get done. If the patient has q2 PTTs ordered, the doctors are probably watching something important or you're titrating a drip med.

Does your unit do bedside reports? Seeing the patient in front of you might help get your thoughts moving when you get report, and also let you ask the outgoing nurse more specific questions, including "does the team know about that?" (However, even if the previous RN says, "yes, I told them about it," if it's something you think is unusual, you should probably call them again! I've run into this a couple of times, complete with an irritated doctor because I *didn't* call them.) You also might be able to do a quick eyeball-survey of the room--check the dates on the IV tubing so you know if you need to change it, see whether you need to bring in more linen or a new toomey syringe for the NG tube, etc...

Depending on the atmosphere of your unit, remember that nursing is a 24-hour gig. If you didn't bathe your patient because their blood pressure was low and you spent a lot of time with the doctor on the phone, and then hanging boluses and/or albumin and/or a pressor, pass the bath on to the next shift! Hopefully they won't give you a ton of grief about it--you were dealing with the more important issue.

I definitely think the more experienced nurses on my unit are better at combining tasks than I am (but I'm getting there...). With a vented, sedated, stable patient, I like to do my assessment at the beginning of the shift (after reviewing orders and making sure there isn't a med due right then). I also do some mouth care, ET suction, check an NGT residual, peri/foley care, and (ideally) get help turning the patient so I can look at their back and also reposition them. If I can do all that, I feel like I've definitely seen everything I need to file my assessment (what color is the sputum? how about the NG aspirate?), and I've also gotten a bunch of tasks out of the way.

Our hospital changed computer systems earlier this year, which definitely set me back a bit in terms of charting! I'm getting used to some tricks that make it a little faster, though...like which flowsheets allow you to copy whole columns into a new time column (copy all of my 0600 IV assessment in the 0700 column at 0615...chances are it won't change by 0700, and I'll edit it if it does).

Hope some of this helps...just some various thoughts based on my last year of learning!

I struggled with this for several months after moving to ICU nursing. While I have encountered the rare individual who simply does not seem to learn from experience, most people do. At first, everything in the ICU is so overwhelming, task based nursing is pretty much the only way one can cope! But once the tasks themselves are easier to handle, you can start flying on autopilot and focusing more on the big picture. Furthermore, as you experience more and more situations, you will begin to develop a greater awareness of your patients.

Let me give you an example. Not too far into ICU nursing, I had a post surgical patient who was breathing pretty fast. He was hurting, so it didn't concern me initially. I asked if he felt short of breath or if he was just hurting. He assured me he was just hurting. The pain medicine ordered was not relieving his pain, so I finally called for new orders. I mentioned to the physician the patient's respirations had been around 30 for a while, but like me, he chalked it up to pain. After giving the new meds, the patient reported his pain was better. Now I was starting to get concerned because he was still breathing really fast. I asked again if he felt okay. He assured me he felt much better. His other vitals were great, heart rate and rhythm perfect--absolutely no signs/symptoms aside from tachypnea. My gut was telling me something was wrong, but my lack of experience was leaving me without answers. I decided to draw my AM labs just after midnight and this guy had a potassium around 7.0. I immediately called and got orders to fix him, but in the few seconds it took me to draw up insulin, this patient went into vfib and coded. Of course, then it hit me that the patient had been acidotic and he'd been breathing fast to compensate, but having never seen such a case without any accompanying symptoms, that hadn't even crossed my mind.

Another night later on, I walked into a fellow new ICU nurse's room to help her turn her patient. The patient had been fine, but I noticed she was breathing really fast. The nurse said she'd denied pain and everything else was fine. Given the experience above, bells and whistles were going off in my head. I knew this patient was acidotic and we were able to get a blood gas and determine the cause long before it became a serious problem.

An experienced ICU nurse might say "Well, duh!" But, for the noob, you have to have some bad situations before you learn to recognize when patients are heading in that direction.

You'll get there!

Great examples here, please keep them coming!

After reading this thread im rethinking my options, i just accepted an offer for CCU position but being an experienced RN on LTC and ZERO critical care, im assigned to 7 months residency program, 5 weeks of classroom and 22 weeks on the unit with preceptor. I graduated long time ago and i feel i have lost alot of skills being just on long term care for 7 years. I was also offered a position on orthopedic unit in a different hospital but since i have been so much interested on CCU, i was leaning towards CCU over orthopedic... i will appreciate on your advice before i make the wrong move...