critical thinking in critical care

Critical thinking in critical care: Five strategies to improve teaching and learning in the intensive care unit

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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.

• Cognitive errors
• Critical care
• Critical thinking
• Medical education

ASJC Scopus subject areas

• Pulmonary and Respiratory Medicine

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• 10.1513/AnnalsATS.201612-1009AS

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• Thinking Medicine & Life Sciences 100%
• Teaching Medicine & Life Sciences 89%
• Critical Care Medicine & Life Sciences 89%
• Intensive Care Units Medicine & Life Sciences 84%
• Learning Medicine & Life Sciences 74%
• Undergraduate Medical Education Medicine & Life Sciences 15%
• Graduate Medical Education Medicine & Life Sciences 13%
• Mentoring Medicine & Life Sciences 11%

T1 - Critical thinking in critical care

T2 - Five strategies to improve teaching and learning in the intensive care unit

AU - Hayes, Margaret M.

AU - Chatterjee, Souvik

AU - Schwartzstein, Richard M.

N1 - Publisher Copyright: © 2017 by the American Thoracic Society.

PY - 2017/4

Y1 - 2017/4

N2 - 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.

AB - 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.

KW - Cognitive errors

KW - Critical care

KW - Critical thinking

KW - Medical education

UR - http://www.scopus.com/inward/record.url?scp=85017222412&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85017222412&partnerID=8YFLogxK

U2 - 10.1513/AnnalsATS.201612-1009AS

DO - 10.1513/AnnalsATS.201612-1009AS

M3 - Article

C2 - 28157389

AN - SCOPUS:85017222412

SN - 2325-6621

JO - Annals of the American Thoracic Society

JF - Annals of the American Thoracic Society

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Critical thinking in healthcare and education

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• Peer review
• Jonathan M Sharples , professor 1 ,
• Andrew D Oxman , research director 2 ,
• Kamal R Mahtani , clinical lecturer 3 ,
• Iain Chalmers , coordinator 4 ,
• Sandy Oliver , professor 1 ,
• Kevan Collins , chief executive 5 ,
• Astrid Austvoll-Dahlgren , senior researcher 2 ,
• Tammy Hoffmann , professor 6
• 1 EPPI-Centre, UCL Department of Social Science, London, UK
• 2 Global Health Unit, Norwegian Institute of Public Health, Oslo, Norway
• 3 Centre for Evidence-Based Medicine, Oxford University, Oxford, UK
• 4 James Lind Initiative, Oxford, UK
• 5 Education Endowment Foundation, London, UK
• 6 Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Australia
• Correspondence to: J M Sharples Jonathan.Sharples{at}eefoundation.org.uk

Critical thinking is just one skill crucial to evidence based practice in healthcare and education, write Jonathan Sharples and colleagues , who see exciting opportunities for cross sector collaboration

Imagine you are a primary care doctor. A patient comes into your office with acute, atypical chest pain. Immediately you consider the patient’s sex and age, and you begin to think about what questions to ask and what diagnoses and diagnostic tests to consider. You will also need to think about what treatments to consider and how to communicate with the patient and potentially with the patient’s family and other healthcare providers. Some of what you do will be done reflexively, with little explicit thought, but caring for most patients also requires you to think critically about what you are going to do.

Critical thinking, the ability to think clearly and rationally about what to do or what to believe, is essential for the practice of medicine. Few doctors are likely to argue with this. Yet, until recently, the UK regulator the General Medical Council and similar bodies in North America did not mention “critical thinking” anywhere in their standards for licensing and accreditation, 1 and critical thinking is not explicitly taught or assessed in most education programmes for health professionals. 2

Moreover, although more than 2800 articles indexed by PubMed have “critical thinking” in the title or abstract, most are about nursing. We argue that it is important for clinicians and patients to learn to think critically and that the teaching and learning of these skills should be considered explicitly. Given the shared interest in critical thinking with broader education, we also highlight why healthcare and education professionals and researchers need to work together to enable people to think critically about the health choices they make throughout life.

Essential skills for doctors and patients

Critical thinking is not a new concept in education: at the beginning of the last century the US educational reformer John Dewey identified the need to help students “to think well.” 3 Critical thinking encompasses a broad set of skills and dispositions, including cognitive skills (such as analysis, inference, and self regulation); approaches to specific questions or problems (orderliness, diligence, and reasonableness); and approaches to life in general (inquisitiveness, concern with being well informed, and open mindedness). 4

An increasing body of evidence highlights that developing critical thinking skills can benefit academic outcomes as well as wider reasoning and problem solving capabilities. 5 For example, the Thinking, Doing, Talking Science programme trains teachers in a repertoire of strategies that encourage pupils to use critical thinking skills in primary school science lessons. An independently conducted randomised trial of this approach found that it had a positive impact on pupils’ science attainment, with signs that it was particularly beneficial for pupils from poorer families. 6

In medicine, increasing attention has been paid to “critical appraisal” in the past 40 years. Critical appraisal is a subset of critical thinking that focuses on how to use research evidence to inform health decisions. 7 8 9 The need for critical appraisal in medicine was recognised at least 75 years ago, 10 and critical appraisal has been recognised for some decades as an essential competency for healthcare professionals. 11 The General Medical Council’s Good Medical Practice guidance includes the need for doctors to be able to “provide effective treatments based on the best available evidence.” 12

If patients and the public are to make well informed health choices, they must also be able to assess the reliability of health claims and information. This is something that most people struggle to do, and it is becoming increasingly important because patients are taking on a bigger role in managing their health and making healthcare decisions, 13 while needing to cope with more and more health information, much of which is not reliable. 14 15 16 17

Teaching critical thinking

Although critical thinking skills are given limited explicit attention in standards for medical education, they are included as a key competency in most frameworks for national curriculums for primary and secondary schools in many countries. 18 Nonetheless, much health and science education, and education generally, still tends towards rote learning rather than the promotion of critical thinking. 19 20 This matters because the ability to think critically is an essential life skill relevant to decision making in many circumstances. The capacity to think critically is, like a lot of learning, developed in school and the home: parental influence creates advantage for pupils who live in homes where they are encouraged to think and talk about what they are doing. This, importantly, goes beyond simply completing tasks to creating deeper understanding of learning processes. As such, the “critical thinking gap” between children from disadvantaged communities and their more advantaged peers requires attention as early as possible.

Although it is possible to teach critical thinking to adults, it is likely to be more productive if the grounds for this have been laid down in an educational environment early in life, starting in primary school. Erroneous beliefs, attitudes, and behaviours developed during childhood may be difficult to change later. 21 22 This also applies to medical education and to health professionals. It becomes increasingly difficult to teach these skills without a foundation to build on and adequate time to learn them.

Strategies for teaching students to think critically have been evaluated in health and medical education; in science, technology, engineering, and maths; and in other subjects. 23 These studies suggest that critical thinking skills can be taught and that in the absence of explicit teaching of critical thinking, important deficiencies emerge in the abilities of students to make sound judgments. In healthcare studies, many medical students score poorly on tests that measure the ability to think critically , and the ability to think critically is correlated with academic success. 24 25

Evaluations of strategies for teaching critical thinking in medicine have focused primarily on critical appraisal skills as part of evidence based healthcare. An overview of systematic reviews of these studies suggests that improving evidence based healthcare competencies is likely to require multifaceted, clinically integrated approaches that include assessment. 26

Cross sector collaboration

Informed Health Choices, an international project aiming to improve decision making, shows the opportunities and benefits of cross sector collaboration between education and health. 27 This project has brought together people working in education and healthcare to develop a curriculum and learning resources for critical thinking about any action that is claimed to improve health. It aims to develop, identify, and promote the use of effective learning resources, beginning at primary school, to help people to make well informed choices as patients and health professionals, and well informed decisions as citizens and policy makers.

The project has drawn on several approaches used in education, including the development of a “spiral curriculum,” measurement tools, and the design of learning resources. A spiral curriculum begins with determining what people should know and be able to do, and outlines where they should begin and how they should progress to reach these goals. The basic ideas are revisited repeatedly, building on them until the student has grasped a deep understanding of the concepts. 28 29 The project has also drawn on educational research and methods to develop reliable and valid tools for measuring the extent to which those goals have been achieved. 30 31 32 The development of learning resources to teach these skills has been informed by educational research, including educational psychology, motivational psychology, and research and methods for developing learning games. 33 34 35 It has also built on the traditions of clinical epidemiology and evidence based medicine to identify the key concepts required to assess health claims. 29

It is difficult to teach critical thinking abstractly, so focusing on health may have advantages beyond the public health benefits of increasing health literacy. 36 Nearly everyone is interested in health, including children, making it easy to engage learners. It is also immediately relevant to students. As reported by one 10 year old in a school that piloted primary school resources, this is about “things we might actually use instead of things we might use when we are all grown up and by then we’ll forget.” Although the current evaluation of the project is focusing on outcomes relating to appraisal of treatment claims, if the intervention shows promise the next step could be to explore how these skills translate to wider educational contexts and outcomes.

Beyond critical thinking

Exciting opportunities for cross sector collaboration are emerging between healthcare and education. Although critical thinking is a useful example of this, other themes cross the education and healthcare domains, including nutrition, exercise, educational neuroscience, learning disabilities and special education needs, and mental health.

In addition to shared topics, several common methodological and conceptual issues also provide opportunities for sharing ideas and innovations and learning from mistakes and successes. For example, the Education Endowment Foundation is the UK government’s What Works Centre for education, aiming to improve evidence based decision making. Discussions hosted by the foundation are exploring how methods to develop guidelines in healthcare can be adapted and applied in education and other sectors.

Similarly, the foundation’s universal use of independent evaluation for teaching and learning interventions is an approach that should be explored, adapted, and applied in healthcare. Since the development and evaluation of educational interventions are separated, evaluators have no vested interested in the results of the assessment, all results are published, and bias and spin in how results are analysed and presented are reduced. By contrast, industry sponsorship of drug and device studies consistently produces results that favour the manufacturer. 37

Another example of joint working between educators and health is the Best Evidence Medical Education Collaboration, an international collaboration focused on improving education of health professionals. 38 And in the UK, the Centre for Evidence Based Medicine coordinates Evidence in School Teaching (Einstein), a project that supports introducing evidence based medicine as part of wider science activities in schools. 39 It aims to engage students, teachers, and the public in evidence based medicine and develop critical thinking to assess health claims and make better choices.

Collaboration has also been important in the development of the Critical Thinking and Appraisal Resource Library (CARL), 40 a set of resources designed to help people understand fair comparisons of treatments. An important aim of CARL is to promote evaluation of these critical thinking resources and interventions, some of which are currently under way at the Education Endowment Foundation. On 22 May 2017, the foundation is also cohosting an event with the Royal College of Paediatrics and Child Health that will focus on their shared interest in critical thinking and appraisal skills.

Education and healthcare have overlapping interests. Doctors, teachers, researchers, patients, learners, and the public can all benefit from working together to help people to think critically about the choices they make. Events such as the global evidence summit in September 2017 ( https://globalevidencesummit.org ) can help bring people together and build on current international experience.

Contributors and sources: This article reflects conclusions from discussions during 2016 among education and health service researchers exploring opportunities for cross sector collaboration and learning. This group includes people with a longstanding interest in evidence informed policy and practice, with expertise in evaluation design, reviewing methodology, knowledge mobilisation, and critical thinking and appraisal.

Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.

Provenance and peer review: Not commissioned; externally peer reviewed.

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Developing critical thinking skills for delivering optimal care

Scott IA, Hubbard RE, Crock C, et al. Developing critical thinking skills for delivering optimal care. Intern Med J. 2021;51(4):488-493. doi: 10.1111/imj.15272

Sound critical thinking skills can help clinicians avoid cognitive biases and diagnostic errors. This article describes three critical thinking skills essential to effective clinical care – clinical reasoning, evidence-informed decision-making, and systems thinking – and approaches to develop these skills during clinician training.

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Treatment patterns and clinical outcomes after the introduction of the Medicare Sepsis Performance Measure (SEP-1). May 5, 2021

Patient perceptions of safety in primary care: a qualitative study to inform care. October 13, 2021

Staffing, teamwork and scope of practice: analysis of the association with patient safety in the context of rehabilitation. December 15, 2021

Use of heuristics during the clinical decision process from family care physicians in real conditions. October 6, 2021

Clinical and economic impacts of explicit tools detecting prescribing errors: a systematic review. May 26, 2021

Diagnostic errors in pediatric critical care: a systematic review. April 28, 2021

Emergency departments are higher-risk locations for wrong blood in tube errors. September 29, 2021

TRIAD IX: can a patient testimonial safely help ensure prehospital appropriate critical versus end-of-life care? September 15, 2021

Survey of nurses' experiences applying The Joint Commission's medication management titration standards. November 3, 2021

Clinical predictors for unsafe direct discharge home patients from intensive care units. October 21, 2020

A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain. July 14, 2021

How providers can optimize effective and safe scribe use: a qualitative study. February 1, 2023

Estimation of breast cancer overdiagnosis in a U.S. breast screening cohort. March 16, 2022

Second victim experiences of nurses in obstetrics and gynaecology: a Second Victim Experience and Support Tool Survey December 23, 2020

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The impact of health information management professionals on patient safety: a systematic review. December 22, 2021

Developing and aligning a safety event taxonomy for inpatient psychiatry. July 13, 2022

Opioids and falls risk in older adults: a narrative review. May 25, 2022

COVID-19: patient safety and quality improvement skills to deploy during the surge. June 24, 2020

Scoping review of patients' attitudes about their role and behaviours to ensure safe care at the direct care level. August 26, 2020

Mitigating imperfect data validity in administrative data PSIs: a method for estimating true adverse event rates. March 3, 2021

Can patients contribute to enhancing the safety and effectiveness of test-result follow-up? Qualitative outcomes from a health consumer workshop. June 2, 2021

Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients. April 21, 2005

Improving patient care. The cognitive psychology of missed diagnoses. April 21, 2005

Quality of life after maternal near miss: a systematic review. June 2, 2021

Missed nursing care in the critical care unit, before and during the COVID-19 pandemic: a comparative cross-sectional study. June 22, 2022

Accuracy of practitioner estimates of probability of diagnosis before and after testing. May 5, 2021

The July Effect in podiatric medicine and surgery residency. July 14, 2021

Medication reconciliation at hospital discharge: a qualitative exploration of acute care nurses' perceptions of their roles and responsibilities. March 23, 2022

"Good catch, Kiddo"--enhancing patient safety in the pediatric emergency department through simulation. December 9, 2020

How can never event data be used to reflect or improve hospital safety performance? May 19, 2021

Healthcare professionals' encounters with ethnic minority patients: the critical incident approach. June 16, 2021

Medication errors' causes analysis in home care setting: a systematic review. February 9, 2022

Development of a core drug list towards improving prescribing education and reducing errors in the UK. March 2, 2011

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'Doing the best we can': Registered nurses' experiences and perceptions of patient safety in intensive care during COVID-19. September 7, 2022

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Development of a multicomponent intervention to decrease racial bias among healthcare staff. July 27, 2022

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The safety of inpatient health care. January 25, 2023

Provider-patient communication and hospital ratings: perceived gaps and forward thinking about the effects of COVID-19. December 16, 2020

Characteristics of critical incident reporting systems in primary care: an international survey. January 19, 2022

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A scoping review exploring the confidence of healthcare professionals in assessing all skin tones. October 4, 2023

Patient safety in palliative care at the end of life from the perspective of complex thinking. August 16, 2023

Only 1 in 5 people with opioid addiction get the medications to treat it, study finds. August 16, 2023

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Explicitly addressing implicit bias on inpatient rounds: student and faculty reflections. June 7, 2023

The time is now: addressing implicit bias in obstetrics and gynecology education. May 17, 2023

Listen to the whispers before they become screams: addressing Black maternal morbidity and mortality in the United States. May 3, 2023

Annual Perspective

Formalizing the hidden curriculum of performance enhancing errors. March 22, 2023

Implicit racial bias, health care provider attitudes, and perceptions of health care quality among African American college students in Georgia, USA. January 18, 2023

Structural racism and impact on sickle cell disease: sickle cell lives matter. January 11, 2023

The REPAIR Project: a prospectus for change toward racial justice in medical education and health sciences research: REPAIR project steering committee. January 11, 2023

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Calibrate Dx: A Resource to Improve Diagnostic Decisions. October 19, 2022

Improved Diagnostic Accuracy Through Probability-Based Diagnosis. September 28, 2022

Medical malpractice lawsuits involving trainees in obstetrics and gynecology in the USA. September 21, 2022

Skin cancer is a risk no matter the skin tone. But it may be overlooked in people with dark skin. August 17, 2022

Narrowing the mindware gap in medicine. July 20, 2022

From principles to practice: embedding clinical reasoning as a longitudinal curriculum theme in a medical school programme. June 15, 2022

A call to action: next steps to advance diagnosis education in the health professions. June 8, 2022

Does a suggested diagnosis in a general practitioners' referral question impact diagnostic reasoning: an experimental study. April 27, 2022

WebM&M Cases

Analysis of the interprofessional clinical learning environment for quality improvement and patient safety from perspectives of interprofessional teams. March 16, 2022

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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.

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

Affiliations.

• 1 1 Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
• 2 2 Shapiro Institute for Education and Research at Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; and.
• 3 3 Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Massachusetts.
• PMID: 28157389
• PMCID: PMC5461985
• DOI: 10.1513/AnnalsATS.201612-1009AS

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.

Keywords: cognitive errors; critical care; critical thinking; medical education.

• Clinical Competence*
• Critical Care*
• Education, Medical, Graduate / methods*
• Intensive Care Units
• Quality Improvement

What is Critical Thinking in Nursing? (With Examples, Importance, & How to Improve)

Successful nursing requires learning several skills used to communicate with patients, families, and healthcare teams. One of the most essential skills nurses must develop is the ability to demonstrate critical thinking. If you are a nurse, perhaps you have asked if there is a way to know how to improve critical thinking in nursing? As you read this article, you will learn what critical thinking in nursing is and why it is important. You will also find 18 simple tips to improve critical thinking in nursing and sample scenarios about how to apply critical thinking in your nursing career.

What Is Critical Thinking In Nursing?

4 reasons why critical thinking is so important in nursing, 1. critical thinking skills will help you anticipate and understand changes in your patient’s condition., 2. with strong critical thinking skills, you can make decisions about patient care that is most favorable for the patient and intended outcomes., 3. strong critical thinking skills in nursing can contribute to innovative improvements and professional development., 4. critical thinking skills in nursing contribute to rational decision-making, which improves patient outcomes., what are the 8 important attributes of excellent critical thinking in nursing, 1. the ability to interpret information:, 2. independent thought:, 3. impartiality:, 4. intuition:, 5. problem solving:, 6. flexibility:, 7. perseverance:, 8. integrity:, examples of poor critical thinking vs excellent critical thinking in nursing, 1. scenario: patient/caregiver interactions, poor critical thinking:, excellent critical thinking:, 2. scenario: improving patient care quality, 3. scenario: interdisciplinary collaboration, 4. scenario: precepting nursing students and other nurses, how to improve critical thinking in nursing, 1. demonstrate open-mindedness., 2. practice self-awareness., 3. avoid judgment., 4. eliminate personal biases., 5. do not be afraid to ask questions., 6. find an experienced mentor., 7. join professional nursing organizations., 8. establish a routine of self-reflection., 9. utilize the chain of command., 10. determine the significance of data and decide if it is sufficient for decision-making., 11. volunteer for leadership positions or opportunities., 12. use previous facts and experiences to help develop stronger critical thinking skills in nursing., 13. establish priorities., 14. trust your knowledge and be confident in your abilities., 15. be curious about everything., 16. practice fair-mindedness., 17. learn the value of intellectual humility., 18. never stop learning., 4 consequences of poor critical thinking in nursing, 1. the most significant risk associated with poor critical thinking in nursing is inadequate patient care., 2. failure to recognize changes in patient status:, 3. lack of effective critical thinking in nursing can impact the cost of healthcare., 4. lack of critical thinking skills in nursing can cause a breakdown in communication within the interdisciplinary team., useful resources to improve critical thinking in nursing, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. will lack of critical thinking impact my nursing career, 2. usually, how long does it take for a nurse to improve their critical thinking skills, 3. do all types of nurses require excellent critical thinking skills, 4. how can i assess my critical thinking skills in nursing.

• Ask relevant questions • Justify opinions • Address and evaluate multiple points of view • Explain assumptions and reasons related to your choice of patient care options

5. Can I Be a Nurse If I Cannot Think Critically?

The university of tulsa Online Blog

Trending topics in the tu online community

Why Critical Thinking Skills in Nursing Are Essential

Written by: university of tulsa   •  feb 29, 2024.

Why Critical Thinking Skills in Nursing Are Essential ¶

Working in health care requires quick thinking and confident decision-making to care for patients. While nurses use a broad range of technical skills to provide quality care, an essential skill that’s easy to overlook is critical thinking. Nursing professionals should explore the benefits of critical thinking skills in nursing, how to apply them, and the ways that advanced education can sharpen their ability to make precise decisions.

Critical Thinking Skills: A Definition ¶

Critical thinking is the process of evaluating facts, interpreting information, and analyzing situations to make informed decisions in various situations. Finding the correct answer to a complex problem isn’t easy. When situations don’t have clear answers and many factors to consider, critical thinking can help individuals move forward and make decisions.

Critical thinking competencies can be applied to a wide range of workplaces and personal situations. In nursing, critical thinking skills can help deliver effective care, handle a patient crisis, and assess the efficacy of treatment plans.

The Importance of Critical Thinking Skills in Nursing ¶

The fast-paced nursing environment requires prompt, data-driven decisions. Nurses use critical thinking daily, reviewing information and making decisions to promote quality care for patients. The following benefits of critical thinking highlight the importance of this skill in nursing careers:

Improves decision-making speed. A critical thinking mindset can help nurses make timely, effective decisions in difficult situations. A systematic method to evaluate decisions and move forward is a powerful tool for nurses.

Refines communication. Improving professional communication allows for factual, efficient, and empathetic conversations with patients and other health care professionals.

Promotes open-mindedness. It’s easy to overlook certain opinions or viewpoints in a high-pressure situation. Thankfully, critical thinking promotes open-mindedness in exploring solutions.

Combats bias. A critical look at different behaviors, contexts, and viewpoints can be helpful for identifying and addressing bias. Nurses must actively seek out ways to confront and remove bias in the workplace.

Critical Thinking in the Nursing Process ¶

There are many ways to apply critical thinking skills to nursing situations. The nursing process is a five-step process to assist nurses in applying critical thinking skills to their daily duties. Experienced nurses and professionals considering a career change to nursing should review the steps as part of their critical thinking process.

Step 1: Assessment ¶

Assessing a patient means far more than taking their vital signs. It also includes collecting sociocultural and psychological data. Lifestyle factors and experiences can affect the treatment process and approach, so skilled nurses review these areas before moving toward the next step, diagnosis.

For example, if a patient reports dizziness or shortness of breath, a nurse should not only check the patient’s temperature, blood pressure, and heart rate but also ask about their family history and recent events.

Step 2: Diagnosis ¶

During the second step, a nurse’s assessment and critical thinking skills produce a clinical judgment. Nurses need to carefully consider all the factors included in the first step. When necessary, consult with other health care professionals before reaching a diagnosis or communicating that diagnosis with the patient.

Discussing a patient’s assessment with other health care professionals requires critical thinking, as the information provided about vital signs, recent events, and family history are key components of this step.

Step 3: Planning ¶

A nurse may be responsible for setting goals and planning a treatment plan for patients. The third step can include setting measurable, achievable goals. Nurses also coordinate care with other health care professionals.

Goals can be simple or complex, depending on the assessment and diagnosis. For example, one patient’s goals may include eating three meals a day, while another’s may include having multiple medications, specialist visits, and physical therapy activities as part of their treatment plan.

Step 4: Implementation ¶

Critical thinking is needed to implement the nursing process, finding ways to carry out the plan with empathy. It’s also important for nurses to document care throughout the fourth step of the process.

For example, nurses should review patient history and consider symptoms before administering medication. Nursing professionals should also think critically about which patients to see first and how to prioritize patients who may need critical attention.

Step 5: Evaluation ¶

Nurses need to continue to evaluate and review the patient’s condition using critical thinking. Evaluation allows nursing professionals to review patient conditions, recommend care plan modification, and consider overall patient status.

For example, identifying whether patients may be ready for a care plan modification or another change in care requires critical thinking and a clear, focused evaluation of multiple patient factors.

How to Foster Critical Thinking Through Nursing Education ¶

Critical thinking is integral to success in the health care field. Thankfully, many ways are available for nurses to improve their critical thinking skills. Below are training, mentoring, and education options for fostering critical thinking.

On-the-Job Training ¶

Because critical thinking is so critical to the daily duties of nurses, experience in the field can improve their ability to evaluate situations and make data-driven decisions. Working firsthand with patients and alongside skilled professionals is a powerful way to see and apply critical thinking in real-world scenarios.

Mentoring Opportunities ¶

Nurses should seek mentorship opportunities for personalized, side-by-side instruction and inspiration from fellow professionals. Mentorships can be either formal or informal opportunities to learn from skilled nurses and health care professionals to promote critical thinking.

Further Education ¶

Many continuing education opportunities are available for nurses. Professionals looking to improve their critical thinking skills should consider enrolling in a course that promotes reflection, evaluation, and analytical thinking.

Review Critical Thinking Skills With The University of Tulsa ¶

Expand your critical thinking skills in nursing by enrolling in a program to earn a degree in the field. The University of Tulsa offers an accelerated online RN to Bachelor of Science in Nursing (RN to BSN) program for students to earn their BSN in as little as 12 months. Take 30 credits of online courses to expand your medical knowledge, general education, and critical thinking abilities. Review the features of this online opportunity to see if it’s the right decision for your career.

Recommended Readings:

The Benefits of Nurse Mentoring

Hospice Nurse: Job Description and Salary

Work-From-Home Safety Checklist: Securing Your Virtual Workspace

American Nurses Association, The Nursing Process

American Nurses Association, What Are the Qualities of a Good Nurse?

Forbes , “The Power of Critical Thinking: Enhancing Decision-Making and Problem-Solving”

Indeed, “Critical Thinking in Nursing (Definition and Vital Tips)”

Indeed, “Critical Thinking Skills in Nursing: Definition and Improvement Tips”

Indeed, “15 Essential Nursing Skills to Include on Your Resume”

StatPearls, “Nursing Process”

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What Are Critical Thinking Skills and Why Are They Important?

Learn what critical thinking skills are, why they’re important, and how to develop and apply them in your workplace and everyday life.

We often use critical thinking skills without even realizing it. When you make a decision, such as which cereal to eat for breakfast, you're using critical thinking to determine the best option for you that day.

Critical thinking is like a muscle that can be exercised and built over time. It is a skill that can help propel your career to new heights. You'll be able to solve workplace issues, use trial and error to troubleshoot ideas, and more.

We'll take you through what it is and some examples so you can begin your journey in mastering this skill.

What is critical thinking?

Critical thinking is the ability to interpret, evaluate, and analyze facts and information that are available, to form a judgment or decide if something is right or wrong.

More than just being curious about the world around you, critical thinkers make connections between logical ideas to see the bigger picture. Building your critical thinking skills means being able to advocate your ideas and opinions, present them in a logical fashion, and make decisions for improvement.

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Why is critical thinking important?

Critical thinking is useful in many areas of your life, including your career. It makes you a well-rounded individual, one who has looked at all of their options and possible solutions before making a choice.

According to the University of the People in California, having critical thinking skills is important because they are [ 1 ]:

Crucial for the economy

Essential for improving language and presentation skills

Very helpful in promoting creativity

Important for self-reflection

The basis of science and democracy 

Critical thinking skills are used every day in a myriad of ways and can be applied to situations such as a CEO approaching a group project or a nurse deciding in which order to treat their patients.

Examples of common critical thinking skills

Critical thinking skills differ from individual to individual and are utilized in various ways. Examples of common critical thinking skills include:

Identification of biases: Identifying biases means knowing there are certain people or things that may have an unfair prejudice or influence on the situation at hand. Pointing out these biases helps to remove them from contention when it comes to solving the problem and allows you to see things from a different perspective.

Research: Researching details and facts allows you to be prepared when presenting your information to people. You’ll know exactly what you’re talking about due to the time you’ve spent with the subject material, and you’ll be well-spoken and know what questions to ask to gain more knowledge. When researching, always use credible sources and factual information.

Open-mindedness: Being open-minded when having a conversation or participating in a group activity is crucial to success. Dismissing someone else’s ideas before you’ve heard them will inhibit you from progressing to a solution, and will often create animosity. If you truly want to solve a problem, you need to be willing to hear everyone’s opinions and ideas if you want them to hear yours.

Analysis: Analyzing your research will lead to you having a better understanding of the things you’ve heard and read. As a true critical thinker, you’ll want to seek out the truth and get to the source of issues. It’s important to avoid taking things at face value and always dig deeper.

Problem-solving: Problem-solving is perhaps the most important skill that critical thinkers can possess. The ability to solve issues and bounce back from conflict is what helps you succeed, be a leader, and effect change. One way to properly solve problems is to first recognize there’s a problem that needs solving. By determining the issue at hand, you can then analyze it and come up with several potential solutions.

How to develop critical thinking skills

You can develop critical thinking skills every day if you approach problems in a logical manner. Here are a few ways you can start your path to improvement:

1. Ask questions.

Be inquisitive about everything. Maintain a neutral perspective and develop a natural curiosity, so you can ask questions that develop your understanding of the situation or task at hand. The more details, facts, and information you have, the better informed you are to make decisions.

2. Practice active listening.

Utilize active listening techniques, which are founded in empathy, to really listen to what the other person is saying. Critical thinking, in part, is the cognitive process of reading the situation: the words coming out of their mouth, their body language, their reactions to your own words. Then, you might paraphrase to clarify what they're saying, so both of you agree you're on the same page.

3. Develop your logic and reasoning.

This is perhaps a more abstract task that requires practice and long-term development. However, think of a schoolteacher assessing the classroom to determine how to energize the lesson. There's options such as playing a game, watching a video, or challenging the students with a reward system. Using logic, you might decide that the reward system will take up too much time and is not an immediate fix. A video is not exactly relevant at this time. So, the teacher decides to play a simple word association game.

Scenarios like this happen every day, so next time, you can be more aware of what will work and what won't. Over time, developing your logic and reasoning will strengthen your critical thinking skills.

Learn tips and tricks on how to become a better critical thinker and problem solver through online courses from notable educational institutions on Coursera. Start with Introduction to Logic and Critical Thinking from Duke University or Mindware: Critical Thinking for the Information Age from the University of Michigan.

Article sources

University of the People, “ Why is Critical Thinking Important?: A Survival Guide , https://www.uopeople.edu/blog/why-is-critical-thinking-important/.” Accessed May 18, 2023.

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• v.8(4); 2021 Jul

Factors associated with the critical thinking ability of professional nurses: A cross‐sectional study

Tuan van nguyen.

1 Faculty of Nursing and Medical Technology, Can Tho University of Medicine and Pharmacy, Can Tho Vietnam

2 School of Nursing, College of Medicine, Chang Gung University, Taoyuan Taiwan

Hsueh‐Erh Liu

3 Department of Rheumatology, Chang Gung Memorial Hospital, Linkou Taiwan

4 Department of Nursing, College of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan

Associated Data

The data that support the findings of this study are available from the corresponding author upon reasonable request.

To measure the level of critical thinking among Vietnamese professional nurses and to identify the related factors.

A cross‐sectional design was used.

The total sample included 420 professional nurses. Data were collected from July to September 2019 in three public hospitals located in Southwestern Vietnam. The level of critical thinking was measured using the Vietnamese version of the Nursing Critical Thinking in Clinical Practice Questionnaire. The data were analysed using the independent Student's t tests, ANOVA, Pearson's correlation and regression analysis.

Most of the participants had a low (48.3%) or moderate (45.5%) level of critical thinking. Age, gender, ethnicity, education level, health condition, duration of working as a nurse, duration of working in the current hospital, having heard the term “critical thinking” and work position had an impact on the critical thinking ability. Work position and gender explained 11% of the total variance in critical thinking ability.

1. INTRODUCTION

Critical thinking is defined as the cognitive process of reasoning that involves trying to minimize errors and to maximize positive outcomes while attempting to make a decision during patient care (Zuriguel‐Pérez et al.,  2015 ). The importance of critical thinking in nursing practice has been identified in the literature (Chang et al.,  2011 ; Ludin,  2018 ; Mahmoud & Mohamed,  2017 ; Yurdanur,  2016 ; Zuriguel‐Pérez et al.,  2015 ). The current nursing environment has become more complex and demanding, especially regarding the acuity and safety of patients and the rapid turnover rate of hospitalization. If professional nurses want to provide high‐quality care, critical thinking is required (Berkow et al.,  2011 ; Brunt,  2005 ; Fero et al.,  2009 ; Zuriguel‐Pérez et al.,  2015 ). Nurses are often the first‐line professionals to observe and provide direct care for patients. Therefore, critical thinking is a necessary skill for them to be able to analyse clinical situations in order to make fast and correct decisions (Lee et al.,  2017 ). More importantly, critical thinking can also improve patient outcomes by preventing habitual thinking that may lead to incorrect medication or procedures (Fesler‐Birch,  2005 ). The critical thinking ability of nurses can have an impact on the patient's safety, and it is a priority in educational programs for healthcare providers (Berkow et al.,  2011 ; Buerhaus et al.,  2006 ). We can identify those with poor critical thinking and provide in‐service education. Although critical thinking has been shown that is influenced by the experience and knowledge acquired during clinical practice (Zuriguel‐Pérez et al.,  2015 ), other personal information needs to be considered to clarifying. Therefore, it is essential to measure the levels of critical thinking and to identify the work‐related and personal‐related factors that influence the critical thinking of nurses.

2. BACKGROUND

The literature has identified that there is a relationship between leadership and positive patient outcomes, such as fewer medication errors and nosocomial infections, lower patient mortality and higher patient satisfaction (Van Dyk et al.,  2016 ; Wong,  2015 ). Alongside leadership, critical thinking is an important factor that supports the management. They can apply critical thinking skills in decision‐making and problem‐solving, and they can develop strategies that help staff nurses to improve their critical thinking ability (Van Dyk et al.,  2016 ; Wong,  2015 ; Zuriguel‐Pérez et al., 2018 ). Thus, the ability to think critically is necessary for nurses because it will help them to effectively make decisions and to solve problems in practice.

Although the importance of critical thinking in nursing practice has been identified, a limited number of studies have been conducted in this population. Particularly, few hospitals have evaluated the critical thinking skills of nurses before employment or during the clinical competency evaluation (Lang et al.,  2013 ). By reviewing 90 articles to assess the current state of the scientific knowledge regarding critical thinking in nursing, Zuriguel‐Pérez et al., ( 2015 ) found that only 16 studies used working nurses as participants. Furthermore, Zuriguel‐Pérez et al., ( 2018 ) reported that few studies have explored the critical thinking ability of nurse managers (NMs). Moreover, several studies have identified that working nurses have a low (Lang et al.,  2013 ; Yurdanur,  2016 ) or moderate level of critical thinking (Chang et al.,  2011 ; Lang et al.,  2013 ; Zuriguel‐Pérez et al., 2018 ). To the researchers’ knowledge, no studies have investigated this issue in Vietnam.

In order to improve the quality and safety of patient care, various types of professional nurses have been established, such as Registered Nurses (RNs), NMs and administrative assistants (AAs). RNs provide direct care to the patients, NMs are responsible for forwarding management and delivering expert clinical care for patients, and AAs are an integral part of maintaining the quality of patient care. The AAs perform administrative tasks (e.g. filing, taking meeting minutes and distributing them and undertaking regular reports) that help NMs to spend more time assisting staff nurses and taking care of patients (Locke et al.,  2011 ). Therefore, RNs, NMs and AAs need to cooperate to help patients to regain their health.

In Vietnam, professional nurses work in three different positions, which are NMs, general nurses (GNs) and AAs (Ministry of Health,  1997 ). Specifically, NMs are recognized as head nurses in Western countries, and their responsibilities are in charge of organizing and implementing comprehensive patient care and conduct a variety of administrative work (e.g. planning and assigning work to nurses, planning the acquisition of tools and consumables, checking care sheets, recording daily labour). GNs are similar to RNs in Western countries, and they provide direct and comprehensive care to patients. AAs perform administrative tasks (e.g. keeping records about the hospitalized and discharged patients, preserving medical records, managing daily medications). They also participate in patients care if necessary (Ministry of Health,  1997 , 2011 ). Although the roles of these three types of professional nurses are different, their final goal is the same to provide holistic care for patients. With the cooperation and effort of these three types of professional nurses, patients can recover. Therefore, more surveys are needed that examine these participants’ level of critical thinking and the associated work‐related factors.

Previous studies have also found that several personal‐related factors are associated with the nurses' critical thinking ability, which are age, gender, ethnicity, education qualification, working experience and shift work (Chang et al.,  2011 ; Feng et al.,  2010 ; Howenstein et al.,  1996 ; Lang et al.,  2013 ; Ludin,  2018 ; Mahmoud & Mohamed,  2017 ; Ryan & Tatum,  2012 ; Wangensteen et al.,  2010 ; Yildirim et al.,  2012 ; Yurdanur,  2016 ; Zuriguel‐Pérez et al., 2018 ). However, the relationships between the critical thinking ability and these variables are inconsistent. For example, age and critical thinking have been found to be positively correlated (Chang et al.,  2011 ; Ludin,  2018 ; Zuriguel‐Pérez et al., 2018 ), negatively correlated (Howenstein et al.,  1996 ) and not related (Lang et al.,  2013 ; Mahmoud & Mohamed,  2017 ; Yurdanur,  2016 ). Gender and critical thinking have been reported with a statistically significant relationship (Liu et al.,  2019 ; Ludin,  2018 ) and no relationship (Mahmoud & Mohamed,  2017 ; Wangensteen et al.,  2010 ). Level of education and critical thinking have been found in a positive association (Chang et al.,  2011 ; Ludin,  2018 ) and not association (Lang et al.,  2013 ; Mahmoud & Mohamed,  2017 ). Year of experiences and critical thinking have been shown to be positively correlated (Chang et al.,  2011 ; Ludin,  2018 ), negatively correlated (Howenstein et al.,  1996 ) and not related (Lang et al.,  2013 ; Mahmoud & Mohamed,  2017 ). Those inconsistent findings indicated the relationships between the personal‐characteristics and the critical thinking ability of professional nurses need further exploration. Therefore, this study aimed to examine the level of critical thinking of professional nurses and to explore the work‐related and personal‐related factors. This is the first study to investigate this issue in Vietnam. The results of the current study will make a significant contribution to the literature because it will provide thorough descriptions of the critical thinking of professional nurses and its associated factors. Furthermore, the findings may be used as a baseline for nurse managers and nurse educators to propose further strategies to improve this ability in professional nurses.

3.1. Research design

A cross‐sectional design was used. The Strengthening the Reporting of Observational Studies in Epidemiology guidelines were applied in this report (Von Elm et al.,  2014 ).

3.2. Setting and sampling

Data collection was carried out from July to September 2019 in three representative and major public hospitals located in the Southwestern region of Vietnam. These hospitals have the same organizational structure, role of treating, operation of professional nursing and provide similar quality of health care to people around that area. The total numbers of professional in these three hospitals nurses were around 1,200. Besides, our study has two steps. The first step was to translate the English version of the Nursing Critical Thinking in Clinical Practice Questionnaire (N‐CT‐4 Practice) into the Vietnamese version. In that step, we used data as a pilot study to estimate the sample size in the second step, which was reported here. Sample size calculation was done by the formula: n  = 1.96 2  × p × (1‐p)/0.05 2 , where p  = .46 came from the poor level of critical thinking among nurses in the first step and 0.05 indicated the acceptable margin of error (5.0%); 382 participants were required by this formula. An additional 10% of participants were done to adjust for potential failures such as withdrawals or missing data (Suresh & Chandrashekara,  2012 ). Therefore, in total, 420 participants were required for this study. Convenience sampling was conducted to recruit the sample. The inclusion criteria were the nurses' employed full‐time employment in the study hospitals. Participants who participated in step 1 or being absent during the data collection such as sick leave or delivering a baby were excluded. Participants were grouped in each hospital and received an envelope with all questionnaires. Then, researchers explained the research's purpose, benefits and risks to the potential participants and the procedure for ensuring confidentiality, and the voluntary nature of the participation. The informed consent form was signed immediately after they agreed to participate in this study. Then, the participants were required to complete the questionnaires in 20 to 30 min and to return them to the data collector.

3.3. Data assessment

3.3.1. sample characteristics.

This instrument collected data about the personal information and occupational variables. The personal information included age, gender, marital status, ethnicity, religion, education level and self‐rated health conditions. The occupational variables were the duration of working as a nurse, the duration of working in the current hospital, the duration of working in the specific position, having heard the term “critical thinking” or not, previous exposure to critical thinking training or education or not, and type of work position.

3.3.2. Vietnamese version of the Nursing Critical Thinking in Clinical Practice Questionnaire ((N‐CT‐4 Practice (V‐v))

The N‐CT‐4 Practice (V‐v) was used to measure the critical thinking ability of the professional nurses. The original instrument (N‐CT‐4 Practice) was established and classified based on the four dimensions of the 4‐circle critical thinking model of Alfaro‐LeFevre (Zuriguel‐Pérez et al., 2017 ). These four dimensions were personal; intellectual and cognitive; interpersonal and self‐management; and technical dimensions. The personal dimension has 39 items to assess the individual pattern of intellectual behaviours; the intellectual and cognitive dimension has 44 items to assesses the knowledge of activity comprehension connected to the nursing process and decision‐making. For the interpersonal and self‐management dimension, it has 20 items to analyse interpersonal abilities that allow for therapeutic communication with patients and health teams and to gain information that is associated with the patient in the clinical environment. The final one, the technical dimension, has 6 items to is concerned with knowledge and expertise in the procedures that are part of the discipline of nursing. This scale has 109 items that are rated using a four‐point Likert response format (1 = never or almost never, 2 = occasionally, 3 = often, and 4 = always or almost always), for example: “I recognize my own emotions.” (item 1); “I have the scientific knowledge required to carry out my professional practice.” (item 40); “I adapt information to the needs and capacities of the patient.” (item 84); “I possess skills in the use of information and communication technologies needed to produce optimal professional results.” (item 105). The total score is obtained from the sum of the 109 items. The scores range from 109–436, and they are categorized into a low level (score <329), moderate level (score between 329–395) and high level (score >395). The overall Cronbach's alpha was 0.96, and the intraclass correlation coefficient (ICC) was 0.77 (Zuriguel‐Pérez et al., 2017).

The N‐CT‐4 Practice (V‐v) was translated, and its psychometric properties were tested with 545 Vietnamese nurses. The results showed that the N‐CT‐4 Practice (V‐v) has acceptable reliability (Cronbach's alpha) and validity (content and construct validity). Particularly, the overall Cronbach's alpha was 0.98, with that of the four dimensions ranging from 0.86–0.97. The ICC was 0.81 over two weeks. The item content validity index was 1.0. Moreover, the goodness‐of‐fit indexes in a confirmatory factor analysis showed acceptable values, which were χ 2 / df  = 2.87, root mean square error of approximation (RMSEA) = 0.059, standardized root mean square residual (SRMR) = 0.063, comparative fit index (CFI) = 0.73 and Tucker Lewis index (TLI) = 0.72 (T. V. Nguyen & Liu,  2021 ). Therefore, the N‐CT‐4 Practice (V‐v) can be used to measure the critical thinking ability of Vietnamese professional nurses.

3.4. Ethical considerations

This study conformed with the ethical principles of the Declaration of Helsinki (Helsinki Declaration,  2013 ), and it was granted research ethics committee approval by the ethical review board of the first author's institution.

3.5. Data analysis

The data were analysed using SPSS for Windows version 23.0 (IBM Corp.), and both descriptive and inferential statistics were calculated. The level of significance for all analyses was set at < 0.05. First, descriptive statistics were employed to summarize the collected data. The continuous variables were described using the mean and standard deviation ( SD ), and the frequency and percentage (%) were used for the categorical variables. Next, independent Student's t tests, analysis of variance (with Scheffe's post hoc comparison) and Pearson's correlation analysis were conducted to explore the association between the critical thinking ability and the personal and occupational factors. Then, a multiple regression analysis using the stepwise method was performed to identify the predictors of critical thinking ability (Pallant,  2010 ).

4.1. Characteristics of the participants

A total of 420 participants completed the questionnaires; the characteristics of overall participants and subjects in each group are listed in Table  1 . Three groups of subjects were included, which were NMs (24.8%), GNs (49.8%) and AAs (25.4%), respectively. Regarding the personal variables, almost all participants were Vietnamese (96.7%), no religion (73.1%) and had good health condition (60%). Meanwhile, the comparison among each group showed that age ( F  = 9.89, p  < .001), gender (χ 2  = 6.48, p  < .05), marital status (χ 2  = 6.77, p  < .05) and education level (χ 2  = 147.38, p  < .001) had reached the statistical significance. Further analysis showed that the age of NMs was significantly older than subjects in both the GN and AA group, AA group had a higher ratio of that in the GN group, and the AA group had a higher ratio of married one than the GN group. For educational levels, subjects in the NM group had a higher ratio of bachelor and master degree, whereas the other two groups had a high ratio of diploma and associate degree.

Characteristics of the participants ( n  = 420)

Abbreviations: AA, Administrator assistant; CT , Critical thinking; GN, General nurse; NM, Nurses manager ; SD , standard deviation.

Chi‐square and one‐way ANOVA test; significant at * p  < .05; ** p  < .01; *** p  < .001.

Regarding work‐related factors, the characters of all participants and subjects in each group are also listed in Table  1 . The comparison of professional experience, such as duration of working as a nurse, duration of working in the current hospital, duration of working in this specific position and heard the terminology of "critical thinking" showed a significant statistical difference among the three groups ( p  < .001). They showed that NMs had a longer duration of working as a nurse (mean = 12.30, SD  = 7.12) and duration of working in the current hospital (mean = 11.6, SD  = 7.02) than the other two groups; GNs had the longest duration of working in the specific position (mean = 7.41, SD  = 6.21). More subjects in the NM group heard the terminology of "critical thinking" than subjects in the other two groups. However, none of the subjects had been exposed to critical thinking training or education. Furthermore, there was a positive correlation among age, the duration of working as a nurse, the duration of working in the current hospital and duration of working in a specific position ( r  = .78–.975, p  < .01).

4.2. Level of the critical thinking of the professional nurses

The mean of the total scores of the N‐CT‐4 Practice (V‐v) for all participants was 333.86 ± 40.22 (with the average score/item = 3.06 ± 0.37), the median score was 331 (interquartile range [IQR] = 311–359), and it ranged from 204–436, which indicates that they generally had a moderate level of critical thinking. Meanwhile, most of the participants reported a low (48.3%) or moderate (45.5%) level of critical thinking. Only 6.2% of the participants had a high level of critical thinking. Regarding the four dimensions of the N‐CT‐4 Practice (V‐v), the average sum score was 119.52 ± 14.19 (with the average score/item = 3.06 ± 0.36) in the personal dimension, 136.38 ± 17.62 (with the average score/item = 3.10 ± 0.40) in the intellectual and cognitive dimension, 68.71 ± 12.65 (with the average score/item = 3.44 ± 0.63) in the interpersonal and self‐management dimension and 18.09 ± 3.01 (with the average score/item = 3.01 ± 0.50) in the technical dimension.

4.3. Work‐related and personal‐related factors associated with critical thinking ability

There were statistically significant associations between the critical thinking ability and some work‐related factors, such as work position ( F  = 23.30, p  < .001), duration of working as a nurse ( r  = 0.15, p  < .01), duration of working in the current hospital ( r  = 0.13, p  < .05) and having heard the term "critical thinking" ( t  = −2.48, p  < .05; Table  2 ). The findings indicated that NMs had higher scores than GNs and AAs. Moreover, nurses who had worked for a longer duration as a nurse or worked longer in the current hospital had a higher critical thinking ability. Meanwhile, those who had not heard the term "critical thinking" had lower scores than participants who had heard this term.

Association between the participants’ characteristics and the critical thinking ability ( n  = 420)

The bolded values indicate the level of statistical significance (with p < .05; p < .01; or p < .001) between the independent and dependent variables.

Abbreviations: SD , standard deviation.

There were statistically significant associations between the critical thinking ability and some personal‐related factors, such as age ( r  = 0.12, p  < .05), gender ( t  = 2.32, p  < .05), ethnicity ( t  = 1.97, p  < .05), education level ( F  = 7.45, p  < .01) and health condition ( F  = 3.14, p  < .05; Table  2 ). The findings indicated that the older nurses reported a higher critical thinking ability, and male nurses had a higher score than female ones. Vietnamese participants had higher scores than participants with other ethnicities. Participants with a bachelor's/graduate degree level of education had higher scores than participants with a diploma and associate degree level of education. Those with very good health had a higher score than participants who rated their health as fair/bad/very bad.

All of the statistically significant variables identified in the univariate analysis were selected as independent variables to determine the predictors of critical thinking ability. For the regression analysis, the categorical variables were first coded as dummy variables. The factors of having never heard of “critical thinking,” being an NM being male, being Vietnamese, having a diploma degree and being in very good health were selected as the standard factors. The results of the stepwise multiple regression method showed that there were only two predictors, namely the variables of work position and gender. Working as an AA or GN or being female can predict the critical thinking ability, and they accounted for 11% of the total variance ( F  = 17.12, p  < .001). This indicates that the AAs and GNs had a lower level of critical thinking than the NMs. Besides, when compared with male nurses, the female nurses exhibited a lower level of critical thinking (Table  3 ).

Predictors of the critical thinking ability ( n  = 420)

5. DISCUSSION

This study showed that the critical thinking ability of most professional nurses was at a low or moderate level. This finding is consistent with previous studies (Chang et al.,  2011 ; Lang et al.,  2013 ; Zuriguel‐Pérez et al., 2018 ). Using the same tool, Zuriguel‐Pérez et al. ( 2018 ) found that the median score of the N‐CT‐4 Practice was 363 (IQR = 340–386) for clinical nurses in Spain. Our study found a slightly lower median score (331; IQR = 311–359) but it was still in a moderate level (range of score: 329–395). Although critical thinking is a relatively new issue in Vietnamese professional nurses, it is not a brand new concept. Certain elements have been included in the nursing curriculum and clinical practice (e.g. the nursing process, problem‐based learning, evidence‐based practice). Therefore, up to 66.7% of participants had never heard the term "critical thinking," but 45.5% still reported a moderate level when measured using the N‐CT‐4 Practice (V‐v).

In Vietnam, clinical professional nurses are categorized into NMs, GNs and AAs with different job descriptions. Critical thinking ability has been identified as an important component for the high quality of care around the world, except in Vietnam. In order to identify this ability, we collected data from 3 hospitals in one region and grouped these data for analysis. Based on the comparison among NMs, GNs and AAs, it was found that NMs had a higher level of critical thinking than GNs and AAs. This can be explained by the fact that NMs have a higher age, work experience and high educational qualification than the other two groups. This result partially supports the finding that NMs report a slightly higher level of critical thinking than RNs (Zuriguel‐Pérez et al., 2018 ). Critical thinking is a necessary skill for effective and efficient management. Evidently, at present, NMs with a high level of critical thinking create positive practice environments that can help the staff nurses to deliver high quality and safe patient care (Zori et al.,  2010 ). Therefore, all healthcare personnel needs to learn and apply critical thinking in order to conduct their work effectively and efficiently.

For clinical nurses, continuous in‐service education is very important to update their knowledge and skill of care. Literature found various factors associated with curriculum design and learning of critical thinking ability. Therefore, grouping subjects in the present study together in order to identify the related factors could help the development of further in‐service education of critical thinking ability effectively and efficiently. In this study, a statistically significant positive correlation was found between the critical thinking ability and age, the duration of working as a nurse and the duration of working in the current hospital. These findings are consistent with previous studies. For example, older nurses have a higher level of critical thinking than younger ones (Chang et al.,  2011 ; Chen et al.,  2019 ; Feng et al.,  2010 ; Ludin,  2018 ; Wangensteen et al.,  2010 ; Yurdanur,  2016 ; Zuriguel‐Pérez et al., 2018 ), and nurses with more experience report a better critical thinking ability than those with less experience (Chang et al.,  2011 ; Chen et al.,  2019 ; Feng et al.,  2010 ; Ludin,  2018 ). Older and experienced nurses are more mature in their way of thinking (Chen et al.,  2019 ; Ludin,  2018 ). Because there were statistically significant positive correlations among age, the duration of working as a nurse and the duration of working in the current hospital. This indicates that older nurses have a longer duration of working as a nurse or working in the current hospital so they have better critical thinking. However, the correlation between these factors and critical thinking in the current study is small; further explorations are suggested.

This study showed that there is a significant association between critical thinking ability and gender and ethnicity, which is also supported by the literature. Ludin ( 2018 ) found that female nurses reported a lower critical thinking ability than male nurses. Traditionally, females have generally had fewer opportunities to receive education and more difficulty asserting their rights during decision‐making than males in Vietnam (L. T. Nguyen et al.,  2017 ). Even today, the phenomenon of gender inequality still exists in certain areas in Vietnam. This traditional burden and the limited opportunities to practice in a clinical care setting might lower the levels of the female participants’ critical thinking. Ethnicity has a similar impact, as found in the present study. For example, it has been reported that Caucasian and Hispanic/Latino participants have a significantly higher critical thinking ability than African American participants (Lang et al.,  2013 ) and that Malaysian and Indian participants report different levels of critical thinking; nevertheless, only 0.9% of the participants were Indian (Ludin,  2018 ). However, in the present study, as almost all of the participants were Vietnamese (96.7%), the skewed distribution of the ethnicity might limit the generalizability of the results. In future studies, an equal distribution of ethnicity is strongly recommended.

This study also confirmed that those who had a bachelor's/graduate degree had a higher level of critical thinking than those who had a diploma or associate degree, even though the former had never heard the term "critical thinking." A vast amount of studies has found that education has a positive impact on the level of critical thinking (Chang et al.,  2011 ; Gloudemans et al.,  2013 ; Ludin,  2018 ; Yildirim et al.,  2012 ; Zuriguel‐Pérez et al., 2018 ). Meanwhile, this study found that participants who had heard the term "critical thinking" displayed a higher level of critical thinking than those who had not heard this term. Education might be the major reason for this variation. In the present study, only 40.7% of participants had a bachelor's/graduate degree. In order to promote their levels of critical thinking, it is necessary to arrange for them, to encourage them, to attend advanced education or to provide further content in the in‐service education.

In this study, participants with very good health had a higher level of critical thinking than participants who self‐rated their health as fair/bad/very bad. Health status does have an impact on work productivity, job performance, quality of care and extra learning (Letvak et al.,  2011 ). Thus, poor health limits their learning and critical thinking ability. This ability is an important predictor of real‐life outcomes (e.g. interpersonal, work, financial, health and education) (Butler et al.,  2017 ). Therefore, the causal effects between health and critical thinking ability need further exploration.

In the current study, only the female gender and the type of work position as an AA or GN were identified as predictors, and they explained only 11% of the total variance of critical thinking ability in the regression model. The uneven distribution of gender and work position might be the reason for the low variance. Even though the male was significantly less than the female, NM was fewer than GN and AA. More factors need to be included in further studies.

The limitations of this study include that it used a convenience sample from only three public hospitals located in the Southwestern part of Vietnam. This sample does not represent all professional nurses in Vietnam. The N‐CT‐4 Practice is the instrument with good psychometric properties specific for clinical practice and translated into English (Zuriguel‐Pérez et al., 2017), Persian (FallahNezhad & Ziaeirad,  2018 ) and Turkish (Urhan & Seren, 2019 ). Different points of the Likert response format were selected by tools to measure critical thinking ability. For example, the N‐CT‐4 Practice selected a four‐point Likert response and it was rated in frequency, such as 1 = never or almost never and 4 = always or almost always. However, a seven‐point Likert scale for the Critical Thinking Disposition Assessment (CTDA) was selected and rated in levels of agreement, such as 1 for very strongly disagree and 7 for very strongly agree (Cui et al.,  2021 ). Which response format can be more reprinting the characters of critical thinking ability? Further investigation is strongly suggested. Besides, the N‐CT‐4 Practice (V‐v) questionnaire has too many items that may lead to the boredom of the participants to answer and thus affect the accuracy of the results. Moreover, the collapsing of three distinctly separate groups of nurses into one group for most of the analyses lead to not showing differences in critical thinking and influencing factors among the three groups. These factors all limit the generalization of the present results. Based on these limitations, it is suggested that the use of nationwide systematic sampling and an international comparison are strongly suggested in further studies. Regarding the critical thinking questionnaire, it would be better to use the revised versions with fewer questions. Therefore, developmental and psychometric properties are suggested to shorten this questionnaire.

6. CONCLUSIONS

The results demonstrate that most of the professional nurses had a low or moderate critical thinking ability. Certain personal and occupational variables were significantly associated with the level of critical thinking. Being male or working as an NM were statistically significant predictors of critical thinking ability, and they explained only 11% of the total variance.

The findings of this study indicate that it is necessary to develop strategies to improve the critical thinking ability of professional nurses. The critical thinking ability has been confirmed to be an essential factor for high‐quality health care that focuses on the quality of patient care and patient safety. Besides, providing more opportunities to pursue advanced degrees or enhancing the provision of in‐service education in hospitals that involves classroom teaching or web‐based learning is strongly recommended for this specific group of nurses. Consequently, the quality of patient care could be improved.

CONFLICT OF INTEREST

The authors declare that they have no competing interests.

ACKNOWLEDGEMENTS

The authors would like to thank the expert panel, translators, research assistants, the hospitals and all of the clinical nurses who participated in this study. We are indebted to the study participants and would like to dedicate the research findings to improving the critical thinking ability of Vietnamese professional nurses in the future. No specific grant was received from funding agencies in the public, commercial, or not‐for‐profit sectors.

Van Nguyen T, Liu H‐E. Factors associated with the critical thinking ability of professional nurses: A cross‐sectional study . Nurs Open . 2021; 8 :1970–1980. 10.1002/nop2.875 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

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thinking critical care

a blog for thinking docs: blending good evidence, physiology, common sense, and applying it at the bedside!

HR24: Acute Inpatient Medicine – Next Level

June 15, 2024, 10-4 EST – Online Webinar Only

Preliminary Schedule:

H&R 2024 Outline: Acute Inpatient Medicine – Next Level! 

Date: June 15 10am-4:30pm EST (7am-1:30pm PST) 

Format: 

• one-day, 6.5 hours, online only
• Pre-recorded lectures
• Live Q&A
• 10am-10:15am: Intro and welcome (15min)
• 10:15am-10:35am: POCUS for shock – Ross Prager
• 10:35am-10:55am: VEXUS tips and tricks – Abhilash Koratala
• 10:55am-11:15am: Ventilators 101 – Segun Olusanya
• 11:15am-11:35am: Q&A 
• 11:35am-11:55am: Dysnatremias in cirrhosis – Eduardo Argaiz
• 11:55am-12:15pm: Top 10 diuretic mistakes – Frederik Verbrugge 
• 12:15pm-12:35pm: Physiology of the shock patient – Ashley Miller 
• 12:35-12:55pm: Q&A
• 12:55pm-1:30pm: Break (35min)
• 1:30pm-1:50pm: The sick aortic stenosis patient – Trina Augustin
• 1:50pm-2:10pm: The sick pulmonary HTN patient – Matt Siuba
• 2:10pm-2:30pm: The seizing ward patient – Casey Albin
• 2:30pm-2:50pm: Q&A
• 2:50pm-3:10pm:  Palliative Medicine pointers – Brittany Rance
• 3:10pm-3:30pm:  Top 5 Geriatric Pearls on the ward – Gurmeet Sohi
• 3:30pm-3:50pm: Sepsis: what we should be doing – Sara Crager
• 3:50pm-4:10pm: Q&A
• 4:10-4:30pm: Concluding remarks (20min)

Also some online-only BONUS lectures – How-To VExUS by Dr. Taweevat Assavapokee!

Registration is OPEN! https://ccusinstitute.wixsite.com/ccus/events/hr2024-acute-inpatient-medicine-next-level-online-webinar

Spiegel & Hockstein Crit Lit HR23!

VExUS/POCUS/Resus Mini-Fellowships 2024

In the last couple of years VExUS has seemingly sparked a number of clinicians to focus on right-sided or venous congestion and its deleterious consequences. Many of us feel there is sufficient associative evidence and physiological basis to use VExUS to manage patients on a daily basis and do so routinely. Currently, several studies we know of (and probably many we don’t!) are on track to show that a VExUS-based approach is likely to be superior to a highly variable traditional approach. In teaching it at the bedside, however, we emphasize the fact that this tool should not be used in a brain-bypass, monosynaptic fashion – all elevated VExUS scores should NOT blindly be diuresed… These ways on how to integrate VExUS in clinical decision-making is what we will emphasize in this part of the Mini-Fellowship.

So due to demand, we have added this specific skill to our Mini-Fellowships which have been going strong for over a decade. The idea (just like in resuscitation!) is to tailor these days to what you need the most. Whether you want to focus on advanced POCUS, looking at coupling parameters and TDI or whether you want to learn to integrate these findings into a resuscitation approach, we will do our best to fill the gaps you may have.

We’ve been organizing mini-fellowships now for over a decade (obviously slowed by the whole pandemic business), because while learning the technical aspect of scanning is one thing, the translation into clinical application and decision-making is altogether another step that, for many, is achieved more readily by witnessing live clinical management.

This year, for the first time, we are adding a specific VExUS element. Participants will be able to pre-emptively watch the online VExUS Course, and then follow a senior instructor for 2-5 days of clinical practice (avg 4-6h/day) where they will be able to observe live scanning and management of real patients both in outpatient, inpatient, ED and ICU settings.

Tuition – Montreal Mini-Fellowships: 600$ CAN / 500$ USD per day for 1 physician, 400$ CAN / 350$ USD per person per day for additional days, and 400$ CAN / 350$ USD per person per day for a 2 to maximum 3 physician group. For physicians who are not from high income countries, do let us know, we will try to help get some industry sponsorship to make it possible.

CME : For Canadians, from the Royal College of Physicians standpoint, the Mini-Fellowships qualify for 25 Section 2 credits (regardless of the length) and 3 hours of Section 3 credits (per day of fellowship). For you Americans:

Through an agreement between the Royal College of Physicians and Surgeons of Canada and the American Medical Association, physicians may convert Royal College MOC credits to AMA PRA Category 1 Credits™. 

Please see the prior posts for participant feedback ( https://thinkingcriticalcare.com/2018/05/09/ccus-institute-pocus-resuscitationist-mini-fellowship-evolution/ ), and if interested, please email [email protected] and we will put you in touch with one of the senior instructors whose time matches your availability.

The H&R Team

H&R’s Advanced Airway & Basic Airway Endoscopy Workshop 2024

The H&R Advanced Airway Workshop 

Santa Cabrini Hospital, Feb 9th, 2024, 1200pm-4pm

Airway/Intubation

Advanced airway skills are a key element of the resuscitationist’s arsenal. In this workshop, participants will be able to tailor their experience and spend as much or as little time as they want in each station to maximize their learning. We will cover basic direct and video laryngoscopy and intubation with and without the use of the bougie as well as bronchoscopic assistance. Emergency surgical airways – both percutaneous and scalper-finger-bougie techniques – will be reviewed and practiced until participants can perform both rapidly and adequately. 

Basic Upper Airway Endoscopy

Endoscopy for basic diagnostic and procedural purposes will be reviewed for obstructive and airway toilet. This will include rhino-pharyngo-laryngoscopy for foreign body/lesion assessment and stridor management in the ER.

Critical Care Endoscopy

Basic bronchoscopy for rapid diagnosis and airway toilet will be covered. This will pertain to most critical care cases where removal of mucus plugs and broncho-alveolar lavage is the bread and butter. Following instruction, each participant will be asked to demonstrate the ability to identify basic anatomy and be able to orient themselves successfully.

Bedside Percutaneous Tracheostomy Course

Participants will spend the last 90 minutes in a separate track focused on the technique and will be asked to perform 5 unassisted techniques to obtain a certificate of adequate completion. {Note that, since this is not an emergency life-saving procedure, this does not qualify the participant to perform the technique independently in clinical practice and will require supervision by an experienced colleague until sufficient experience is attained.}

Participants & Registration

There will be 15 complimentary trainee registration slots and 20 spots for practicing physicians (249$/199$ for CEMTL MDs) and 5 spots including the percutaneous tracheostomy course (349$). Participants will receive a link to pre-course material to watch prior to the workshops. Lunch will be included. There is no formal CME accreditation for this event.

Registration link: https://ccusinstitute.wixsite.com/ccus/events/hsco-hr-airway-course-2024

The Faculty : Dr. Joe Nemeth (ER), Dr. Philippe St-Arnaud – (ER/Critical Care) Dr. Lawrence Leroux (ER/Anaesthesia), Dr. Andy Nguyen (Respirology), Dr. Olivier Abboud (Otolaryngology), Dr. Ian Ajmo (Critical Care), Dr. Philippe Rola (Critical Care).

Welcome and Lunch – 1230-1300

Stations A: 1300-1400

– Basic DL/VL station (St-Arnaud, Ajmo)

– The Art of the Bougie (Rola)

– Bronchoscopy-guided intubation (Leroux, Nemeth)

– Rhino/pharyngo/laryngoscopy – (Abboud)

Stations B: 1400-1500

– Emergency percutaneous cricothyrotomy (St-Arnaud/Rola)

– Emergency Surgical Airway (Scalpel-Finger-Bougie) (St-Arnaud/Rola)

– Emergency Tracheostomy (Nemeth)

– Bronchoscopy for toilet/foreign body extraction (Nguyen)

Percutaneous Tracheostomy w/ Bronchoscopy Assistance (Ajmo/Rola) 1430-1600

Open Practice and Q&A: 1500-1600

HR2023 Highlights: Matt Siuba on a Practical Approach to VA Coupling!

So HR2023 was awesome. So many good talks and workshops, as well as some fantastic hallway discussions with both faculty and participants!

I will be sharing several of the talks on #FOAMed and wanted to start with what I think is hands-down the best practical clinical talk on VA coupling. Matt, as a true clinician and bedside physiologist, finds a way to take a complex topic and make it understandable and usable. Kudos!

For those interested in the rest of the #HR23 lectures, they can be found here, with CME to come in the next weeks.

Super excited for this. No issues with travel this year, the H&R family all keen on getting together again, the lineup is awesome, most of the OGs able to make it, lots of new additions, and the programme is looking really sweet. Am totally amped to have Katie Wiskar as the Chair of The Hospitalist as she’s putting together a great group with sharp lectures and super interesting workshops. With help from the usual suspects (Rory Spiegel, Andre Denault, Korbin Haycock) we are focusing on some core areas in acute and critical care – sepsis, arrest and respiratory failure are perennials, but this year we are also adding neurocrit as a core component, which I think is a bit underserved and certainly deserving of more.

A message from Katie Wiskar: I cannot express how excited I am to be a part of H&R 2023, and to finally get to experience the magic in person. Building on the energy and ethos that Philippe has curated in the Resuscitation side, I’m thrilled to bring a killer set of on-demand lectures and in-person content delivered by a top-notch, multi-disciplinary faculty. The program is full of hot topics, evidence-based medicine updates, and practical ward pearls. I can’t wait to learn from this group of incredible educators; and I hope to see you all there! 

When? September 27-30 with the core being 28-29 and the pre/post stuff on either side.

Where? Montreal – both at the Heart Institute (core days) and my shop, Santa Cabrini Hospital (pre/post courses).

CME? Of course, should be over 40 credits, watch this space in the next weeks.

What? So you get a bunch (about 50) lectures to watch prior to the conference, then during the in-person part, you get some live lectures followed by group discussions around those topics, as well as hands-on workshops. You can hop between the Hospitalist and the Resuscitationist tracks depending on your interest or mood. Most importantly, there’s plenty of hallway time where you get to hunt down the universally open minded and available faculty members to pick their brains, share ideas, start collaborations and who knows what else you might come up with. This is gold. There’s going to be a buffet of workshops to pick and choose from that we are still putting together, from airway management to bedside procedures, ekg workshops, neuro exam workshop, wound dressing, and of course all kinds of POCUS.

Oh yeah, and the pre/post stuff is pretty fantastic. If you’ve been following acute care and POCUS, you’ve noticed the beginning of an ear where we will focus on fluid tolerance rather than responsiveness, and VExUS is a pretty important part of it. Learn from the originators and other pioneers of the score in this VExUS course with real patients and pathology. If you struggle with refractory hypoxia in acute lung injury, add APRV-TCAV to your armamentarium. Understand the mode, shake off the myths and learn knobology on a couple of ventilators with simulated lungs. You do trauma or medical resus? REBOA is growing in use. Familiarize yourself with the technique using the different available aortic occlusion catheters with the REBOA course . The Resuscitative TEE Course , run by none other than Felipe Teran is back again! If you’re not personalizing your CPR, here’s the place to learn!

The Hospitalist POCUS Course will be split in Basic (AM) and Advanced (PM) and the focus will be on all core skills required at the inpatient level. The faculty is absolutely top notch.

A newcomer this year is the Jr. Doc Procedure Course , aimed at trainees but truly good for anyone entering the hospital arena, regardless of age or training status. Go over and practice intubation and basic airway management, central and arterial line placement, thoracic and abdominal pigtail insertion and more!

And of course, the Introduction to Brazilian Jiu Jitsu workshop is always a blast. Last year, participants were treated to a short philosophical discussion on breathing with guru coach Firas Zahabi followed by a hands-on training session. In previous years we had reviewed basic concepts to stay safe in volatile situations. Always a lot of fun! We are fortunate to have some pretty seriously BJJ-skilled faculty members such as Ashley Miller and Rory Spiegel! Can’t wait!

Who? So the H&R family keeps growing!

On the H side, Katie has assembled an impressive lot that I am really looking forward to meeting and exchanging with, such as Gigi Liu, Michael Fralick, Elaine Kilabuk, Ria Dancel and more to be confirmed!

On the R side, we have many of the usual (awesome) suspects, Korbin Haycock, Rory Spiegel, Matt Siuba, Segun Olusanya, Felipe Teran, Jeff Scott.

Some young guns like Ben Daxon, Trina Augustin, Max Hockstein, Eduardo Argaiz, Vimal Bhardwaj, Frederick Verbrugge and Jay Chatterjee.

Some who joined us virtually last year but whom I am totally psyched about meeting some in person such as Katie Wiskar, Abhilash Koratala, Casey Albin, Neha Dangayach, Ashley Miller, Hatem Soliman, Mourad Senussi and Sara Crager.

Not to mention some icons of emergency and critical care like Scott Weingart, Ognen Gajic, Sheldon Magder, Andre Denault, Ashish Khanna, Jan Bakker and Glenn Hernandez who have contributed so much to the literature.

…and we keep adding talks and faculty! Bookmark this to keep up!

For the preliminary programme and more information , https://hr2023.sched.com/

Registration is open! https://ccusinstitute.wixsite.com/ccus/events/the-hospitalist-the-resuscitationist-2023

See you there!!!

Etomidate: a perspective on a current controversy.

Personally, I’ve never used it, so not really an issue to me. But it seems to generate a fair bit of emotion and debate, and having the pleasure of knowing some really smart and, in this case, highly experienced people, I think we have something good to share here, a story from Thomas Woodcock! This insight may help clinicians currently debating the issue…

Edomidate – A Brief Personal History.

By Thomas Woodcock, MD.

We all want Evidence, good solid peer reviewed communications with verifiable data, ideally randomised and controlled. But we are human, and our practices are also informed by unpublished experience, what used to be cited as “Personal communications”. I acknowledge the dangers of placing too much confidence in such evidence. Our recollections of events may become clouded or unreliable as the years pass. With that caution in mind, I am going to take the final opportunity to offer my unpublished recollections of events surrounding Iain Watt’s fortuitous discovery of the lethality of the intravenous anaesthetic agent etomidate back in 1983; forty years ago, though it only seems like yesterday.

This year our friends at San Raffaele Scientific Institute, Milan, Italy published a meta-analysis of studies reporting the use of etomidate to cover tracheal intubation in critically ill patients and concluded as follows;

We included 11 randomized trials comprising 2704 patients. We found that etomidate increased mortality (319/1359 [23%] vs. 267/1345 [20%]; risk ratio (RR) =  1.16; 95% confidence interval (CI), 1.01–1.33; P =  0.03; I2 = 0%; number needed to harm = 31). The probabilities of any increase and a 1% increase (NNH ≤100) in mortality were 98.1% and 92.1%, respectively. [1]

This came as no surprise to me, and was predictably followed by etomidate anaesthetists explaining that the harm (euphemism for lethal effect) could only be proven by enrolling thousands of participants in a blinded RCT. Imagine the Consent form.

We have a broad selection of intravenous anaesthetic agents to offer for your general anaesthetic, but one of them has had serious concerns raised about a lethal effect. With your permission we would like to randomise you to receive a safe drug or etomidate so that we can learn more about the lethal effect.

In 1983 I was an Englishman abroad, the London anaesthetist who was appointed to be the English anaesthetist on the Shock Team only because the outstanding candidate from Oxford had preferred to take up a job doing muscle relaxant research with Kitz and Katz in the USA. The Western Infirmary Glasgow (WIG) was a Victorian red brick building on the Byres Road. The Boss was Professor Iain McAllister Ledingham, Editor of the book series Recent Advances in Critical Care Medicine, a founder of The European Society of Intensive Care Medicine and one of its first Presidents. With many original publications on shock and interhospital transfer, in the clinic and in the laboratory, Iain Ledingham was as reverered as Pope John Paul II who had been granted an audience with the Prof during the first Papal visit to Glasgow in 1982. A photograph recording the event was prominent on Iain’s desk. As an American visitor to the Unit observed, this was surely the best Intensive Care service in England (sic) [2] . Up to 1982, intensive care patients at WIG were being sedated with propofol infusions, opioids and benzodiazepines, but by the time I arrived the preferred hypnotic was etomidate with morphine analgesia. It may be that the change was prompted by a 1982 report from Sheffield entitled “Safer sedation for ventilated patients. A new application for etomidate.” [3] The ICU looked to me like something out of the 1978 movie Coma, based on the novel by Michael Crichton. Most patients were sedated to immobility with the new wonder drug that had no histamine release and a stable haemodynamic profile – except, of course, for the patients who were also receiving dopamine. Nursing tasks were thus greatly simplified, and the staff were able to enjoy a post round morning tea break at which everybody was offered an egg “piece”. [4]

The research agenda at the time was broad. Complement activation and histamine release were blamed for capillary permeability changes in shock, and imbalance between the arachnadonic acid metabolites was blamed for arteriolar dysfunction and microvascular coagulation. Adam Fleck had his own team investigating the transcapillary escape rate of albumin in severe disease and injury. To everybody outside Glasgow glucocorticoids seemed to be the answer and Chicago surgeon William Schumer was their chief flag waver, claiming in 1976 that steroid therapy reduced the mortality of saline-treated sepsis in his service from 33% to around 10%. [5]   We had all witnessed the almost miraculous Shock Reversal that often followed the infusion of 30 mg/kg methylprednisolone (Solumedrone in the UK). Upjohn Pharmaceuticals sent their representatives around the country to ensure that every intensive care physician was aware of this. When I told a London Upjohn Representative that I was heading to Glasgow, he warned me that WIG may be the only UK service refusing to treat sepsis with high dose steroids. He predicted that by the time I returned from Glasgow any lingering doubts about the life-saving power of Solumedrone would have been cast off.

When I arrived in Scotland I was tasked with investigating the effects of the thromboxane synthase inhibitor dazoxiben on prostaglandin production in sepsis patients. [6] Once a week, on Dr Winifred Finlay’s ICU ward round, we would be joined by biochemist Dr McKee and patient adrenal function test results were reviewed. These ladies had published their findings on serum cortisol levels in severely stressed patients the year before. [7] Now, hydrocortisone was being prescribed for patients deemed to need it, targetting a “normal” stressed serum cortisol and this seemed to be reducing mortality. [8] I was bold enough to ask Prof Ledingham why he was opposed to “pharmacological dose” steroid therapy, and he merely pointed out that the research evidence was very poor. More studies were needed. Finlay and McKee’s surprising data had been shared with Joe Stoddart, a respected Intensivist in Newcastle, England. Joe replied that he had looked at twenty consecutive “severely stressed” Geordie ICU patients, and without exception they had appropriately high serum cortisol levels. You are giving them something harmful, he concluded.

The surgical Shock Team Registrar was Ian Watt, a rather reserved chap with an Aberdonian sense of humour [9] . The Shock Team day started with an early morning debrief in the Laboratory. The Team was Ledingham, two anaesthetic Registrars, one Surgical Registrar, Technicians Ian and Morag, Secretary Dianne and, quite often, a greyhound. Our clinical responsibilities included the advanced management of shock patients. Only the Shock Team were allowed to do right heart catheter haemodynamic studies, and I was entrusted with Ed Sivak’s double indicator dilution machine that measured the extravascular thermal volume of the lungs. We Registrars were each On Call for two weeks, with one week off. This meant that we could dispatch two Shock Team members to any hospital in Scotland, to stabilise and if necessary bring shocked patients into WIG, any time of any day or night. One of us would be the designated Ambulance driver. But I digress, let’s talk more about Iain and the greyhound. At the end of the debrief the Registrars would head off to the ICU to join their rounds, but on days when Ian was experimenting on a dog one of us might stay behind to help him anaesthetise, intubate, ventilate and catheterise the animal. [10] He was using the Gurll model to investigate hypovolaemic shock. The stabilised animal was allowed to bleed until the mean arterial pressure was around 45mmHg. This hypovolaemic shock state was to be maintained for one or two hours before the shed blood was retransfused and the effect of experimental drugs on resuscitation could be tested. [11] The problem was that Iain’s greyhounds died during the hypotensive phase. I do not recall one experiment getting as far as the resuscitation stage. We pooled our intellects on the challenge, and decided that maybe the choice of pedigree greyhounds was an issue. Glaswegians, after all, are not easily compared to thoroughbreds and so Iain acquired some mongrel dogs. Unsurprisingly they died during hypotension too. Ian was getting desperate. In need of data for a Master of Surgery degree, he decided to change tack and get stuck into some clinical research. An anaesthetic Senior Registrar called Richard Marsh was our computer geek – he kindly took me to an international Computing In Anaesthesia and Intensive Care meeting in Rotterdam, where I think he presented a paper. Richard was constructing a relational database of severity of illness scores and intensive care outcome at WIG. He was alarmed to observe a big step-wise increase in ICU mortality occurring in 1982, and Watt’s new research brief was to investigate. The Shock Team had an office with three desks, one for each of us. My own desk was untidy, but Ian’s desk grew an ever increasing tower of patient records with his own notes and annotations. Then came his Eureka moment. Focusing on the cohort of major trauma patients, for whom one could calculate an expected mortality, he confirmed a very sharp rise in the observed mortality at the time there was a switch to etomidate sedation. Moreover, he found that almost all of the adrenal insufficient patients in the Finlay & MacKee series were sedated with etomidate. I obtained plates with cultures of human adrenocortical cells from Glasgow Medical researchers and added various anaesthetic agents in concentrations approximating therapetic plasma levels, before adding ACTH to stimulate cortisol release. I was sure I would find all sedative or analgesic medicines could inhibit cortisol release, but I was very wrong. Etomidate was a very powerful adrenocortical inhibitor. Perhaps the mystery was solved. Then one morning an investigation team representing Janssen arrived. They took over the shock team office, poring over the patient records and Ian’s research notes. For several days I could not get to my own desk. We reassessed Ian’s abysmal animal research history, and realised he had decided to anaesthetise the dogs with etomidate, in line with local clinical practice. He rushed back to the Laboratory to anaesthetise dogs with other anaesthetics and was relieved to find he could successfully run a Gurll model experiment. He used etomidate again, and found that a shot of hydrocortisone enabled dogs to survive long enough to reach the resuscitation stage. How could the Sheffield team have claimed that etomidate provided safer sedation for ventilated patients back in 1982? The reason became clear. Their case series was just 6 healthy patients ventilated for 24 hours after major maxillofacial surgery, and each had received dexamethasone to prevent surgical swelling.

Iain knew he had a responsibility to communicate his discovery as rapidly and widely as possible. This is why he chose a Letter to the Lancet. Unfortunately this prior publication caused some Editors of scholarly journals to turn down his more thoroughly considered and detailed manuscripts that should have followed. The Scottish national press reported that deaths had been caused by etomidate at WIG, but the anticipated public outcry did not materialise. We were spared the ignominy of an Inquiry. The number of Glaswegians whose lives were lost to etomidate was never ascertained. Experts came forward to claim that etomidate was still a preferred hypnotic induction agent for patients who would benefit from its haemodynamic stability, even though this claimed superiority was never demonstrated in sick patients. In the UK the Committee for Safety of Medicines merely drew attention to potential hazards of etomidate administration. In Denmark, the license to infuse etomidate was limited to 12 hours,

Silly comments from Experts included “it only happened in trauma patients who stayed ventilated for 5 days or more” and “a shot of hydrocortisone will block the lethal effect”. Should regulatory authorities have done more to prevent the continued use of this poison?

There are post scriptums  to this story. In November 1984 Charles Sprung and colleagues published a landmark trial showing that impressive early shock reversal with high dose corticosteroids was NOT associated with increased survival of patients with severe, late septic shock. [12]   I had been offered a critical care research post for 1985-6 at The Victoria Hospital, London, Ontario but Upjohn withdrew their research funding and so I had to seek alternative employment. I went instead to a Fellowship at The University of Western Ontario (UWO) in London. [13]

When Charles Sprung later devised and led an international multicentric study on Hydrocortisone Therapy for Patients with Septic Shock (CORTICUS) I was pleased to be a contributing investigator. [14]

A final PS that I forgot to add is that my notoriety in the adrenal insufficiency arena got me tasked with a Working Party on the topic back in 2012. We did not achieve a publishable consensus until 2020. 15  I thought it might be impossible. Anaesthetists in the UK severely underestimate the dangers of poor & inconsistent management in critical care. Many accused us of overstating the danger, while the endocrinologists were dismayed at the lack of commitment to do better.

______________________

Co-Published on Osler https://osler.app.link/1uB7SSRwUzb on May 18 th , 2023

[1] J Crit Care 2023 Apr 29. 77:154317. 10.1016/j.jcrc.2023.154317

[2] I asked the distinguished visitor where the best intensive care unit in the world was; The Vic, in London Ontario was his confident answer. Iain agreed. And so I later went on to spend a year in that welcoming town, and met William (Bill) Sibbald).

[3] PMID: 7048991

[4] In Glaswegian, a piece is a toasted slice of bread split into two thin slices. The usual filling was a tiny spread of scrambled egg.

[5] https://doi.org/10.1016/j.jcrc.2023.154317

[6] Dazoxiben almost completely blocked the synthesis of thromboxane A2, but there was no discernable change in the patients shock state.

[7] Lancet 1982 Jun 19. 1:1414-5. 10.1016/s0140-6736(82)92531-4

[8] Lancet 1983 Feb 26. 1:484. 10.1016/s0140-6736(83)91489-7

[9] Humour was important in Glasgow at that time, as a young Billy Connolly was making national headlines as an outstanding comedian. I was told that Winifred was the daughter of Scotland’s most famous comedian Alec Finlay.

[10] We each had a Home Office License to conduct terminal animal experiments under anaesthesia. An Inspector called from time to time to ensure our work was humane.

[11] It is an under appreciated fact that much of the post haemorrhagic shock fatality occurs during resuscitation.

[12] N Engl J Med 1984 Nov 01. 311:1137-43. 10.1056/NEJM198411013111801

[13]  I became the first researcher to report measurements of cerebral blood flow and cerebral metabolic rate for oxygen during cardiac surgery with induced hypothermia on cardiopulmonary bypass. I was allowed to spend occasional days at the Vic when my contractual commitments at UWO allowed.

[14] N Engl J Med 2008; 358:111-124 DOI: 10.1056/NEJMoa071366

15 Anaesthesia 2020 May. 75:654-663. 10.1111/anae.14963

Fluid Tolerance: A Concept. #FOAMed

Here is a lecture I gave for the International Fluid Academy annual meeting which is truly a terrific event. Many of us have been working hard at ushering in this concept, which we feel is vastly more important than that of fluid responsiveness.

And for those interested, here is our paper: https://pubmed.ncbi.nlm.nih.gov/35660844/

Venous Congestion Spanish Style: Dr. Curro Miralles-Aguiar! #FOAMED, #FOAMCC, #VEXUS

So I’ve been meaning to put this up for a while, along with many other #FOAMed lectures I want to share and get out there in our neverending quest to cut down on the KT on bedside physiological management. For years now I have enjoyed collaborating with my friend Curro Miralles, who is a fantastic clinician on top of being the latin leading man heir apparent to Antonio Banderas who somehow ended up as a physician instead. Well, medicine should be greateful! Enjoy!

VExUS Demystified: Hangin’ with Korbin & Rory.

It’s always a good time hanging with these guys (@khaycock2 and @Emnerd). Over the years I’ve learned a ton from them. Even if I thought I was pretty solid on something, they almost always have the ability to shed some additional light on it in a particularly useful way. So I always look forward to these discussions. Today we took some time to flesh out some of the questions and statements that came up about VExUS in the last few days on medtwitter.

Hope you all enjoy!

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