promoting critical thinking in your intensive care unit team

Promoting Critical Thinking in Your Intensive Care Unit Team

January 2022
Critical Care Clinics 38(1):113-127
38(1):113-127

Harvard Medical School

Beth Israel Deaconess Medical Center

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DOI: 10.1016/j.ccc.2021.08.002
Corpus ID: 244163106

Promoting Critical Thinking in Your Intensive Care Unit Team.

J. Richards , R. Schwartzstein
Published in Critical care clinics 1 January 2022
Medicine, Education

5 Citations

Critical thinking in medical education, development and validation of a delirium care critical-thinking scale for intensive care unit nurses: a mixed-method study., educational priorities and programs for the development of research competencies in science-based medical education, construction of an evaluation index system of core competencies for critical care blood purification nurses in china: a delphi study., diagnostic momentum in physical therapy clinical reasoning., 55 references, scoping review of critical thinking literature in healthcare education, milestones of critical thinking: a developmental model for medicine and nursing, critical thinking in health professions education: summary and consensus statements of the millennium conference 2011, clinical reasoning and risk in the intensive care unit., teaching clinical reasoning: case-based and coached., constructing critical thinking in health professional education, medical students' critical thinking assessment with collaborative concept maps in a blended educational strategy, reducing diagnostic error in the intensive care unit. engaging uncertainty when teaching clinical reasoning, clinical review: medication errors in critical care, can concept mapping be used to promote meaningful learning in nurse education, related papers.

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critical thinking , critical care nursing , orientation

Swinny, Betsy MSN, RN, CCRN

A lot of resources are spent on the development of new staff in the intensive care unit (ICU). These resources are necessary because the environment in the ICU is complex and the patients are critically ill. Nurses need an advanced knowledge base, the ability to accurately define and change priorities rapidly, good communication and teamwork skills, and the ability to work in a stressful environment in order to succeed and give their patients quality care. Critical thinking helps the nurse to navigate the complex and stressful environment of the ICU. Critical thinking includes more than just nursing knowledge. It includes the ability to think through complex, multifaceted problems to anticipate needs, recognize potential and actual complications, and to expertly communicate with the team. A nurse who is able to think critically will give better patient care. Various strategies can be used to develop critical thinking in ICU nurses. Nurse leaders are encouraged to support the development of critical-thinking skills in less experienced staff with the goal of improving the nurse's ability to work in the ICU and improving patient outcomes.

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Assessing and Developing Critical-Thinking Skills in the Intensive Care Unit

Swinny, Betsy MSN, RN, CCRN

Baptist Health System School of Health Professions, San Antonio, Texas.

Corresponding Author: Betsy Swinny, MSN, RN, CCRN, Baptist Health System School of Health Professions, 8400 Datapoint Dr, San Antonio, TX 78229 ( [email protected] ).

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Webinar Date: March 7, 2023

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

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

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

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

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Teamwork in the Intensive Care Unit

Jennifer n. ervin.

1 University of Pittsburgh

Jeremy M. Kahn

Taya r. cohen.

2 Carnegie Mellon University

Laurie R. Weingart

Intensive care units (ICUs) provide care to the most severely ill hospitalized patients. Although ICUs increasingly rely on interprofessional teams to provide critical care, little about actual teamwork in this context is well understood. The ICU team is typically comprised of physicians or intensivists, clinical pharmacists, respiratory therapists, dieticians, bedside nurses, clinical psychologists, and clinicians-in-training. ICU teams are distinguished from other health care teams in that they are low in temporal stability, which can impede important team dynamics. Furthermore, ICU teams must work in physically and emotionally challenging environments. Our review of the literature reveals the importance of information sharing and decision-making processes, and identifies potential barriers to successful team performance, including the lack of effective conflict management and the presence of multiple and sometimes conflicting goals. Key knowledge gaps about ICU teams include the need for more actionable data linking ICU team structure to team functioning and patient-, family-, ICU-, and hospital-level outcomes. In particular, research is needed to better delineate and define the ICU team, identify additional psychosocial phenomena that impact ICU team performance, and address varying and often competing indicators of ICU team effectiveness as a multivariate and multilevel problem that requires better understanding of the independent effects and interdependencies between nested elements (i.e., hospitals, ICUs, and ICU teams). Ultimately efforts to advance team-based care are essential for improving ICU performance, but more work is need to develop actionable interventions that ensure that critically ill patients receive the best care possible.

The intensive care unit (ICU) is a specialized hospital unit dedicated to the care of patients requiring life-support and those at extremely high risk for organ failure and death. Approximately 5.7 million individuals are admitted to an ICU in the United States each year ( Barrett, Smith, Elixhauser, Honigman, & Pines, 2011 ). ICUs care for the most severely ill hospitalized patients, and in doing so are one of the most resource demanding and stressful areas of the hospital. The field of critical care medicine has embraced a standard whereby care is provided by an interprofessional team of clinicians ( Weled et al., 2015 ). Under such a model, intensivists (i.e., physicians with specialized training in intensive care medicine) or other types of attending physicians collaborate with and capitalize on the interprofessional expertise of bedside nurses, respiratory therapists, clinical pharmacists, dieticians, and clinical psychologists ( Durbin, 2006 ).

Recent shifts toward interprofessional care have resulted in lower morbidity and mortality rates among ICU patients ( Curtis et al., 2006 ). However, little about actual teamwork in the ICU is well understood. Few existing studies focus on the form and function of interprofessional collaborations among critical care clinicians or provide insight as to how these relationships influence team performance. As a result, critical care providers lack guidance on how to leverage team function in order to improve patient outcomes and reduce health care costs in the ICU. In this review we address this gap by synthesizing extant research on teamwork in the ICU and providing a roadmap for future research in this domain. First, we describe the extent to which ICU teams are similar to and yet distinct from teams in other organizational contexts. Second, we review the existing research on team performance in the ICU. Third, we highlight key areas for future study, including outcome indicators that reflect effective team processes.

Characteristics of Intensive Care Teams

The social scientific definition of a team is “a distinguishable set of 2 or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal/object/mission, who have each been assigned specific roles or functions to perform” ( Salas, Dickson, Converse, & Tannenbaum, 1992 , p. 4). When defined in this manner, effective team performance is contingent upon conflict, cooperation, coordination, coaching, communication, and cognition between team members ( Salas, Shuffler, Thayer, Bedwell, & Lazzara, 2015 ). Analogously, team-based medicine refers to care that requires the expertise and coordinated efforts of two or more clinicians. Successful ICU teams are able to exchange information and work together on some shared goal or task, such as managing an artificial respirator, providing intravenous sedation to keep patients comfortable, or dealing with the emotional distress of family members whose loved ones are critically ill.

There is no single defining feature that makes the ICU a unique context for collective behavior; rather, ICU clinicians face a combination of specific structural and situational demands that differentiates them from members of other organizational and healthcare teams. These include but are not limited to differences in the lifespan of ICU teams and the physical and emotional challenges faced by those working in the ICU (e.g., Salas et al., 2015 ). With regard to lifespan, ICU teams are low in temporal stability in that the identity of individual team members changes from day to day ( Alexanian, Kitto, Rak, & Reeves, 2015 ; Andreatta, 2010 ; Hughes et al., 2016 ). Yet unlike other health care teams that are low in temporal stability, such as cardiac resuscitation teams or trauma teams, the tasks for ICU teams are longer in duration than the life of each team. For example, a single patient might spend 14 days or longer in an ICU, during which time team composition and related dynamics are in flux ( Wildman, Shuffler, Lazzara, Fiore, & Burke, 2012 ).

ICU teams function in spite of low temporal stability because the persons fulfilling each position are expected to bring shared knowledge about caring for critically ill patients and shared expectations about their specific roles in the ICU ( Alexanian et al., 2015 ). Formal and informal hand-off processes also contribute to team functioning in this setting of variable team membership. Formally, hand-off protocols can improve the efficiency and effectiveness of face-to-face communication during shift changes, reducing errors, improving continuity and reducing uncertainty about patient goals of care ( Patterson, Roth, Woods, Chow, & Gomes, 2004 ). Informally, unstructured handoffs ( Ong, BiomedE, & Coicera, 2011 ) and electronic health records that, if properly maintained, allow clinicians to access, update, and manage patient information, contribute to continuity of care ( Hoover, 2017 ).

ICU teams are also distinguished by the unique physical and emotional constraints that affect team performance. With regard to the physical environment of the ICU, near constant alarms, uneven lighting, poorly placed equipment, and space limitations mean that the physical environment is at best not helpful and at worst harmful to the goals of team-based critical care (Alameddine et al., 2008; Salas, Cooke, & Rosen, 2008 ; Shortell et al., 1994 ; Xie & Carayon, 2015 ). Perhaps in response to the substantial variation that exists in the use of physical space, as well as the recognition that many hospitals and ICUs do not use space optimally, hospital and ICU design is a burgeoning area of multidisciplinary research (e.g., Rashid, 2006 ; Thompson et al., 2012 ). Early results from this research suggest that open floor plans, easy circulation around the patient’s bed, clear lines of sight between nursing stations and rooms, and single-patient rooms can improve communication and family satisfaction with care ( Kesecioglu, Schneider, van der Kooi, & Bion, 2012 ).

With regard to the emotional constraints, death and dying is a daily occurrence in the ICU, forcing the team to function in a highly charged emotional environment characterized by persistent grieving and moral distress ( Embriaco, Papazian, Kentish-Barnes, Pochard, & Azoulay, 2007 ; Henrich et al., 2016 ). Despite having access to support, emotional distress is common among care providers and spreads easily to other team members, which can increase collective anxiety and reduce team performance ( Picquette, Reeves, & LeBlanc, 2009 ).

These unique characteristics of ICU teams have several implications for critical care. First, effective communication is a necessity. In this context, effective communication refers to the ability to transfer information, ideas, and opinions across team members with widely varying backgrounds, experiences, and skill-levels (e.g., Reader, Flin, Mearns, & Cuthbertson, 2009 ). Second, ICU team members must trust in others’ knowledge, skills, and training so that teams can perform in high stakes situations despite little or no shared history ( Hughes et al., 2016 ; Wildman, et al., 2012 ). Third, team leadership should balance authority with inclusiveness while establishing shared goals and fostering sense of shared responsibility for patient care ( Fernandez & Grand, 2015 ; Manthous & Hollingshead; 2011 ; Manthous, Nembhard, & Hollingshead, 2011 ). In order to facilitate team learning and foster a sense of psychological safety, ICU team leaders must talk openly about mistakes and difficulties in order to create a culture where there is no fear of retribution for clear and candid communication about potential problems (e.g., Edmonson, 2012 ).

Team Performance in the Intensive Care Unit

The goals of ICU teams are multifold. In most published research, patient outcomes in general, and mortality rates specifically, are the most common metric of ICU team performance. Although mortality rates are a commonly used performance metric, they are not necessarily the best indicator of success considering that end-of-life care is a primary treatment administered in the ICU. The goal of end-of-life-care is to agree upon desired outcomes and achieve realistic goals of care; yet many of these decisions are complex (i.e., many factors must be considered by families and care providers) and sometimes even controversial, which can complicate coordination of care (e.g., Cook & Rocker, 2014 ).

Thus, mortality should not be the only indicator for determining successful ICU team performance. Other goals include but are not limited to improving health-related quality of life among ICU survivors, improving the quality of death and dying among ICU decedents, acting as efficient stewards for health care resources by avoiding waste, and tending to the needs of family members with loved ones in the ICU. However, understanding team performance is complicated by the fact that these goals do not always align. For example, heroic efforts to save lives are costly, necessitating time and expensive technology. In contrast, early deaths are inexpensive. In this way, an ICU team with high performance along the domain of mortality can be a low performer along the domain of costs. These tensions have several implications for how we understand ICU team performance. First, it is difficult to characterize effective teams, in that high performance along one domain does not necessarily translate to high performance along another domain. The challenge for efforts to improve ICU teamwork, then, is to identify not only what kinds of processes or interventions could improve specific outcomes, but also to elucidate boundary conditions and unintended negative consequences of different practices. Second, it demonstrates the need for ICU teams themselves to define their goals and agree upon their prioritizations. Goal priorities will vary from patient to patient within a single day and over time, and to the degree that ICU teams do not a priori agree on the goals for a given patient, team performance can never be optimized.

Acknowledging the issue of competing goals, in the following sections we review the literature on ICU team performance with a focus on risk-adjusted mortality rates, as mortality is by far the most commonly employed performance metric in the literature. For clarity, we also focus on studies examining adult general, non-specialty critical care, although the issues we discuss also apply to specialty units such as neonatal ICUs, pediatric ICUs, and neurological ICUs.

Team Composition

ICU teams are typically composed of an intensivist physician, a clinical pharmacist, a dietician, several respiratory therapists and bedside nurses, and other health care providers such as clinical psychologists. The intensivist, a physician with specialized training in critical care medicine, is the leader of the team and has ultimate responsibility for medical decision-making. An extensive body of literature demonstrates that the presence of an intensivist as team leader as opposed to a physician without specialty critical care training, is associated with lower mortality ( Wilcox et al., 2013 ), yet little is known about the underlying reasons for this observation. The conventional wisdom is that intensivists bring experience and expertise in the care of critically ill patients that non-intensivist physicians do not possess, which may lead to improve leadership skills and improved team performance ( Cooke et al., 2008 ; Kahn, Brake, & Stenberg, 2007 ).

Current professional guidelines recommend intensivist-led care for all ICU patients, although not all ICUs in the United States conform to this standard ( Weled et al., 2015 ). One reason for such variability is that over the past decade the interprofessional care model has also become more prevalent ( Kohn et al., 2017 ). Patient care under this model relies on collaborations from experts from various domains (e.g., respiratory therapy, clinical pharmacy, critical care nursing, clinical psychology) in the ICU. With the increasing popularity of the interprofessional care model, the value of an intensivist appears to be decreasing, as interprofessional providers have gained expertise and are able to take a more active role in caring for patients, thus diffusing medical decision-making responsibilities across members of the care team. In addition, the increased use of protocols and other communication tools has lessened the need for intensivist-led care ( Costa, Wallace, & Kahn, 2015 ; Kohn et al., 2017 ; Wilcox et al., 2014; Yoo, Edwards, Dean, & Dudley, 2014 ).

Clinical pharmacists provide unique expertise on drugs that are the cornerstone of ICU treatment. Drug administration and dosages can be highly influential on patient outcomes, and intensivist physicians might not possess all of this information at the ready. Data demonstrate that the presence of a clinical pharmacist in the ICU is associated with lower adverse drug events and improved patient outcomes ( Kane, Weber, & Drasta, 2003 ; Leape et al., 1999 ; Rivkin & Yin, 2011 ; Stone et al., 2011 ).

Dieticians provide unique expertise for patients’ nutritional needs, and must account for the problem that feeding protocols are often contingent upon other therapies ( Cahill, Dhaliwal, Day, Jiang, & Heyland, 2010 ). For example, when and how patients are provided nutritional support is in part determined by whether they are placed on a ventilator, their level of alertness, and their immune system functioning. Therefore, dieticians must collaborate with all members of the ICU team to ensure that patients receive adequate and timely nutritional support.

Respiratory therapists typically oversee the provision of mechanical ventilation, which is the central supportive therapy for patients experiencing respiratory failure and among the most common ICU treatments ( Netzer et al., 2011 ; Stamm, 2005). Although the provision of mechanical ventilation is collaborative by nature, respiratory therapists possess unique expertise and experience in how to operate the ventilator, and, like pharmacists, their involvement in care is associated with lower mortality in the ICU ( Ely et al., 1996 ).

Nurses are, among other things, responsible for closely monitoring and reporting changes in patients’ health and wellbeing ( Baggs et al., 1999 ; Knoll & Lendner, 2008 ). Unlike other members of the ICU team who care for most if not all patients at any given time, nurses only care for a subset of patients, typically no more than two at any one time. Yet nurses are central members of the ICU team because they are directly involved in nearly all ICU treatments, in that they are responsible for assessing vital signs, delivering drugs, and monitoring for complications of therapy. Greater nursing education and expertise is associated with lower mortality among ICU patients ( Kelly, Kutney-Lee, McHugh, Sloane, & Aiken, 2014 ).

When available and able to join the care team, clinical psychologists and other behavioral healthcare specialists play a unique role in that they specifically address patients’ psychological recovery and they provide care for patients, families, and critical care providers. Particularly noteworthy is that patients who receive care by a clinical psychologist have lower rates of anxiety, depression, and post-traumatic stress following admission to the ICU ( Nova & Ballesteros de Valderama, 2006 ; Peris et al., 2011 ).

Some team members might be in training to become critical care providers, and may come from any of the above disciplines. Most common are physicians-in-training (i.e., medical students, interns, residents, and fellows), and advanced practice providers (APPs) who are nurse practitioners and physician assistants being trained to perform many of the same tasks as an attending physician. The presence of clinicians-in-training is positively associated with role clarity, as well as the frequency and quality of information exchanges among ICU team members ( Hawryluck, Espin, Garwood, Evans, & Lingard, 2002 ; Joffe, Pastores, Maerz, Mathur, & Lisco, 2014 ; Valentin & Ferinande, 2011 , but see Almoosa, Goldenhar, Puchalski, Ying, & Panos, 2010 ; Costa, Wallace, Barnato, & Kahn, 2014 ). And, while there has been some concern that reliance on nurse practitioners and physician assistants in training might negatively impact patient outcomes, findings suggest that this is not the case (e.g., Costa et al., 2014 ).

Each of the clinician types possesses a diverse array of knowledge acquired through different training pathways. In turn, each possesses unique skills, jargon, and status within the team ( Alexanian et al., 2015 ; Azoulay et al., 2009 ; Ferrand et al., 2003 ; Kho, Carbone, Lucas, & Cook, 2005 ). These differences can improve the quality of care but can also lead to ineffective interprofessional interactions and conflict among the clinicians. These interprofessional conflicts tend to be multifactorial, making them difficult to solve. Importantly, unresolved conflict can impede open exchanges of information and reduce appreciation of one another’s expertise ( Mitchell, Parker, Giles, & Boyle, 2014 ; Wright, Bowkett, & Bray, 1996), which delays and reduces the quality of patient care ( Azoulay et al., 2009 ; Lindgard, Epsin, Evans, & Hawryluck, 2004 ; Ten Have & Nap, 2014 ; Wysham et al., 2017).

In the modern ICU, family members are increasingly considered to be part of the ICU team, especially when they take on the role of surrogate decision makers for loved ones who are too ill to advocate for themselves. The practice of family participation on medical rounds has received the most attention in this area, with data suggesting that while rounds are traditionally viewed as a forum for collaboration among clinicians, they can also be used for collaboration with family members, including information exchanges and reducing decisional conflict ( Davidson et al., 2017 ). However, some clinicians feel that family presence can disrupt important communication processes ( Jacobowsky, Girard, Mulder, & Ely, 2010 ; Reeves, et al., 2015 ; Santiago, Lazar, Jiang, & Burns, 2014 ). For instance, clinicians have expressed reluctance to engage in candid discussions about patient prognoses while in the presence of family members ( Au, des Ordons, Soo, Guienguere, & Stelfox, 2016 ; Azoulay et al., 2009 ; Huffines et al. 2013 ; Maxwell et al., 2007 ).

Team Collaboration and Decision Making

The foundation of ICU team collaboration and decision-making is daily rounds. Rounds are the formal, daily face-to-face meetings that are attended by most if not all of the ICU clinicians that are directly involved with patient care ( Hawryluck et al., 2002 ). On rounds each ICU patient is discussed either at the bedside or in another area such as a hallway or conference room. As a conduit for team processes, rounds provide a context for critical care providers to share information and engage in shared decision-making processes. Rounds also serve as a platform for clinicians to share their experiences and advice concerning critical care more broadly, such as sensitive issues regarding patient and family communication, strategies for dealing with difficult situations, and to provide other forms of psychosocial support ( Lown & Manning, 2010 ). Rounds are typically structured such that clinicians work systematically through all of the patients admitted to the ICU on a given day, meaning that as the team moves through the ICU, team member rotate in and out of the discussion such that the composition of the team varies from patient to patient.

Due to their ephemeral nature, collaborative information sharing during rounds is a difficult endeavor. Effective rounds allow clinicians to openly exchange information about patient care, which should result in fewer knowledge- and/or training-related errors ( Hawryluck et al., 2002 ; Kim, Barnato, Angus, Fleisher, & Kahn, 2010 ; Montague, Lee, & Hussain, 2004 ). Yet rounds are frequently interrupted by phone calls and clinical emergencies, which disrupts flow and increases the amount of time clinicians spend during rounds, thereby limiting the time left in the day to care for patients or communicate with family members ( Alverez & Coicera, 2005 ; Fackler, Watts, Grome, Miller, Crandall, & Pronovost, 2009 ; Giri et al., 2013 ; Hawryluck et al., 2002 ; Ward, Read, Afessa, & Kahn, 2012 ). Clinicians will often compensate for anticipated interruptions by withholding information during rounds to speed up the process, which can increase the efficiency yet the decrease the effectiveness of rounds as a communication tool ( Costa et al., 2014 ).

While rounds represent formal communication procedures in the ICU, informal information sharing and decision making will often take place between small subsets of members of the team throughout the day ( Alexanian et al., 2015 ; Costa et al., 2014 ). These types of informal interactions are particularly prevalent when (a) rounds are not conducted in a timely manner, (b) family member presence makes clinicians reticent to discuss negative patient prognoses or other sensitive information, and (c) clinicians are unsure of their positions and/or lack the psychological safety needed to speak up in the presence of other team members during rounds. While informal discussions cannot be avoided altogether, they are problematic in that they perpetuate information gaps among care providers.

Checklists and Protocols

To overcome barriers to effective formal and informal collaboration, many ICUs have developed communication and decision-making strategies to facilitate team functioning and performance. For example, many ICUs have implemented checklists or daily goal forms to promote effective communication among clinicians ( Gawande, 2009 ). These tools systematize the ways that clinicians discuss key treatments, and provide structure and guidelines for interactions that should establish shared goals of care and clarify clinicians’ roles. Checklists and protocols are meant to streamline care, which is an important consideration in that many critical care providers report time constraints as one of the biggest challenges to providing high quality care ( Azoulay et al., 2009 ; Dodek & Rabound, 2013; Narasimhan, Eisen, Mahoney, Acerra, & Rosen, 2006 ; Idahosa & Kahn, 2002; Pronovost et al., 2003 ; Ward et al., 2013 ; Weiss et al., 2011 ). However, implementation of these tools can be time consuming and reduce complex decisions to rote processes, which can lead to fatigue. These types of protocols also do consistently improve patient outcomes (Writing Group for the CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network, 2017).

Other Determinants of ICU Team Performance

ICU team performance is determined not only by effective coordination and conflict management, but also by organizational and environmental characteristics exogenous to team processes and protocols. As suggested by the existing literature, team formation and rounding processes appear to be the most consequential factors to consider for influencing team performance, and therefore the likely levers for change to be targeted by future interventions.

First, with regard to staffing decisions, our takeaway from the research is that it is not necessarily whether an ICU has an intensivist present that is at issue, but rather the extent to which a team leader is able to help overcome barriers to effective communication that are inherent in interprofessional and interdisciplinary teams. Having an intensivist lead the ICU team might help mitigate problems associated with status differences and jargon unique to a clinician’s specialty, and to provide role and goal clarity ( Hawryluck et al., 2002 ; Kim et al., 2010 ), but there may be other ways to address these processes that do not require an intensivist on the team.

Second, rounding processes represent the time when ICU teams are most “team like,” in that most members are present and have the option to speak up during rounds, and shared goals can be established and/or maintained. As such, we believe that practices that facilitate effective problem solving and the establishment of psychological safety during rounds will have positive carryover effects as team members interact throughout the day. Thus, interventions aimed at improving ICU team functioning should target team-level behaviors that influence communication, conflict, and group decision-making during rounds.

Future Directions

Improving ICU teams will require research and quality improvement efforts that draw directly from the team science literature, which can provide relevant theories and concepts that will elicit a better understanding of whether and how various psychosocial factors develop and influence team effectiveness over time. Extant studies predominantly focus on leadership and psychological safety, but many other theories and concepts potentially apply to ICU teams. For example, conflict can have either positive or negative effects on team performance depending on situational and team factors ( De Dreu & Weingart, 2003 ; de Wit, Greer, & Jehn, 2012 ). Yet little is known beyond the fact that (a) nurses and intensivists report engaging in the most conflict (e.g., Azoulay et al., 2009 ), and (b) nurses engage in a fair amount of (negative and sometimes abusive) conflict with other nurses ( Alspach, 2007 ). Future work on ICU teams should examine different sources of conflict ( Cronin & Weingart, 2007 ) as well as the frequency, intensity, and expression of different types of conflict ( Weingart, Behfar, Bendersky, Todorova, & Jehn, 2015 ) in order to determine more effective ways to manage conflict in the ICU.

Another issue that currently lacks resolution is how precisely to define an ICU “team.” At one extreme, the most inclusive characterization would define the team as all ICU staff, to include administrators and those only indirectly involved with patient care. However, such a definition ignores important interdependencies among clinicians who work together to provide direct care for patients, and discounts temporal dynamics related to team composition ( Shortell et al., 1994 ). At the other extreme, a minimal definition would characterize an ICU team as two clinicians working together to provide a given treatment to a given patient at a particular point in time. By this definition, though, ICU teams are probably too transitory to warrant attempts to make generalizations across teams or ICUs. Future research should consider linking daily team composition (of those directly involved with the care of a given patient) and related dynamics to quality care indices and patient outcomes over time. The literature on multiple team membership could inform this research ( Marks, DeChurch, Mathieu, Panzer, & Alonso, 2005 ; O’leary, Mortensen, & Woolley, 2011 ) and make for an exciting new research direction that informs our understanding of ICU team functioning and multiple team membership more generally. An alternative but equally fruitful approach could apply network analysis to evaluate dynamics of critical care providers and ICU teams as parts of a larger multi-team system ( Poole and Contractor, 2012 ).

Finally, efforts to reconcile the varying and often competing measures of ICU team effectiveness and performance is needed. Considering the increased reliance on team-based care in the ICU, it is paramount that we continue to elucidate connections between the team processes and patient-, family-, ICU-, and hospital-level outcomes. Moreover, risk-adjusted mortality alone does not allow the identification of how to leverage the team when accounting for the varying and sometimes contradictory goals of these stakeholders. Reader et al. (2009) offered a model to categorize and test the impact of team inputs and processes on different ICU team outcomes. An adapted version of this model can help account for different ways the team will influence and can produce optimal levels of patient satisfaction and quality care, or lower staff burnout and turnover, health care costs, or one of the many other potential outcomes of interest.

For the most part we have refrained from commenting on interventions, as thorough reviews on medical teams are available elsewhere (e.g., Hughes et al., 2016 ), and we are somewhat agnostic as to whether unique features of the ICU enable the generalization of that work to teams in this domain. Furthermore, most of the critical care research to date is focused primarily on academic medical centers. Due to idiosyncrasies and differences across community samples, we also know little about how teamwork might operate differently within these settings. Nevertheless, the ultimate goal we share with others is to understand how to provide better team-based care and intervene with informed evidence-based practices when necessary.

In the meantime, both clinical psychologists and researchers in the field of psychology can approach the ICU as an opportunity to extend our understanding of team functioning in health care, one in which the existing research demonstrates the importance of role clarity, psychological safety, and leader inclusiveness in teams that are both highly hierarchical and low in temporal stability. With extremely high stakes, not only for patients at risk of death and disability but also family members and providers at risk for psychological distress and burnout, the team is likely to play an increasingly vital role in ensuring the ICU meets its goal of saving lives by ensuring that critically ill patients receive the best care possible.

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Published: 12 August 2011

Building effective critical care teams

Constantine Manthous 1 ,
Ingrid M Nembhard 2 &
Andrea B Hollingshead 3

Critical Care volume 15 , Article number: 307 ( 2011 ) Cite this article

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Critical care is formulated and delivered by a team. Accordingly, behavioral scientific principles relevant to teams, namely psychological safety, transactive memory and leadership, apply to critical care teams. Two experts in behavioral sciences review the impact of psychological safety, transactive memory and leadership on medical team outcomes. A clinician then applies those principles to two routine critical care paradigms: daily rounds and resuscitations. Since critical care is a team endeavor, methods to maximize teamwork should be learned and mastered by critical care team members, and especially leaders.

The fragility of critically ill patients leaves little margin for mismanagement. To offer these most vulnerable patients the greatest chance of high-quality survival, all members of the care team must 'know their stuff' and administer their crafts in a complex, coordinated fashion. World Cup champions survive the tournament through teamwork. Since the 'unit of administration' in critical care units is not the physician but rather 'the team', it is reasonable to assume that team dynamics impact out-comes as much - or more - in medicine. However, simply employing a team-based structure in a critical care unit does not ensure improved patient outcomes. We here explore three behavioral science concepts - psychological safety, transactive memory and leadership - that have been positively associated with team performance in previous research. They are harnessed daily - often unconsciously - in most critical care teams, and can be fortified to enhance care. We then show how these principles apply and can be cultivated in routine, day-to-day activities of the critical care team.

Lessons from team science

Lesson 1: cultivate psychological safety.

Research conducted in health care and other settings indicates that psychological safety plays a central role in whether expertise diversity, status differences, and temporary membership - all of which are attributes of health care teams - facilitate or hinder team effectiveness. Psychological safety refers to the degree to which individuals perceive their work environment as supportive of interpersonally risky behavior, such as asking questions, seeking help, reporting mistakes, raising concerns, or offering suggestions [ 1 ]. Individuals can perceive that engaging in these behaviors, which is necessary for team effectiveness, elevates the risk of being seen as ignorant, incompetent, disruptive or negative [ 2 ]. This risk is minimal in psychologically safe teams; their members believe that they will not suffer punishment, embarrassment, or any form of negative consequence as a result of engaging in these behaviors [ 3 ].

Research shows that health professionals often feel psychologically unsafe [ 4 – 8 ]. A series of studies conducted in a variety of hospital units found that only 55% of staff feel comfortable speaking up even when they perceived a problem with patient care [ 5 – 7 ]. The sense of psychological safety mirrors the professional hierarchy. A study of over 1,400 health professionals from 23 neonatal intensive care units found that physicians felt significantly greater psychological safety than nurses, who felt safer than respiratory therapists [ 8 ]. The latter (non-physicians) reported that it was more difficult to bring up problems and tough issues. A national study of health professionals found that non-physicians do not speak up with concerns because they fear blame, retaliation, punishment, and belittling response [ 9 ]. Between 30% and 50% of nurses report that nurse input is not well-received in their units [ 6 , 7 ].

Studies have shown that patients treated in settings in which staff feel psychologically unsafe often experience adverse events [ 9 – 11 ]. For example, a cross-sectional study of the relationship between hospital climate and clinical performance showed that hospitals in which staff reported greater fear of shame and blame had significantly greater risk of 12 patient safety indicators established by the Agency for Healthcare Research and Quality [ 11 ].

Team and organizational research indicates that poor performance occurs because professionals in psychologically unsafe teams are less likely to engage in behaviors that contribute to team effectiveness [ 12 ]. First, they do not speak up with concerns and suggestions, which is critical for coordinating efforts, rectifying errors, and improving processes [ 13 , 14 ]. For example, Edmondson [ 4 ] found that nurses in psychologically unsafe units spoke up less about medication errors. Less knowledge-sharing in psychologically unsafe places has been found in a variety of organizational settings, ranging from restaurant chains to web services to aircraft component manufacturing [ 15 ].

Second, individuals in psychologically unsafe teams engage less in team learning [ 1 ]. Learning is critical to team effectiveness, particularly in contexts such as health care where teams constantly implement new practices. A series of follow-up studies on the aforementioned 23 neonatal intensive care units showed that units with higher psychological safety used significantly more learning activities (for example, dry runs). In turn, they also experienced more successful implementation of new practices and 18% lower patient mortality after 2 years [ 16 , 17 ].

Lastly, studies have also shown that psychological safety predicts problem-solving, another contributor to team effectiveness. A study of 37 (intensive care, medical/surgical, and maternity) units in 14 hospitals showed that nurses in more psychologically safe units were more likely to participate in efforts to help solve systemic problems [ 18 ]. Likewise, in such units, there were less workarounds [ 19 ].

Lesson 2: enable the development of transactive memory

Experienced teams often solve problems better than newly formed teams [ 20 ]. One explanation for why team performance improves over time is that experienced teams often develop a transactive memory system that enables them to make better use of each individual's knowledge, skills and abilities [ 21 ].

A transactive memory system is a group-level memory system that often develops in close relationships and work teams. It involves the division of knowledge responsibilities among team members with respect to the encoding, storage, retrieval and communication of information from different knowledge areas and a shared awareness among team members of 'who knows what' and 'who will do what' [ 22 ]. A useful metaphor for describing transactive memory is a set of networked computers each containing different information but with a common directory [ 23 ]. The division of responsibilities among members of critical care teams are likely to reflect formal roles such as 'physician' or 'nurse' but others may relate to team member's unique skills and experiences.

For example, one member of the team may be especially good at calming family members while another may be especially good at finding a good vein for an IV. Accurate and shared knowledge about each member's roles and responsibilities on the team often translates into more effective communication processes: members know who to ask, what to ask, when to ask, and how to ask for information from others in the system, and they can anticipate when and how to communicate information effectively to those who need it [ 24 ].

Team behaviors associated with a well-developed transactive memory include: specialization, credibility, and task coordination [ 25 ]. As team members gain an understanding of one another's skills and expertise, they develop knowledge that is different but complementary (specialization). However, this occurs only if they trust in their teammates' expertise (credibility). Task coordination (ability of team members to coordinate their work efficiently) occurs as members develop high levels of specialization and credibility leading to high team performance.

One necessary condition for transactive memory development is cognitive interdependence: individuals must perceive that their outcomes are dependent on the knowledge of others, and those others' outcomes are dependent on their knowledge [ 26 ]. This provides the motivation for team members to attend to what others can potentially contribute to the team. Cognitive interdependence can be instilled in teams in a number of ways: through team simulations and team training, team-based rewards and the development of positive work relationships. Informal interactions and shared experiences through daily rounds provide opportunities for members to learn about the relative expertise of other members, to coordinate who does what, to observe members' skills in action, and to build positive relationships. Those systems set up by formal design (such as a listing of staff responsibilities or procedures in an ICU training manual) are either validated or modified over time as the team discovers whether individuals assigned to specific roles are capable and willing to perform them [ 27 ].

It takes time to develop a well functioning transactive memory system. Physicians in newly formed medical teams may not always know what information is needed by other team members. In a simulation of emergency medical diagnosis, twenty teams of either two or three physicians who had never worked together performed a patient handoff using a human patient simulator. In most of these teams, the physician who held the patient's chart did not read the earlier diagnosis, and did not talk to the room. As a result, many teams made the incorrect diagnosis because the physician with the chart did not understand the information needs and roles of other team members [ 28 ].

A primary supposition of the increasing use of simulation training for complex medical tasks/teams, including critical care resuscitation, asserts that transactive memory is an essential component of building highly performing teams. Although there are no systematic studies conducted in critical care that have compared the performance of new and experienced teams, Hunziker and colleagues [ 29 ] examined 50 teams that performed cardiopulmonary resuscitation simulation exercises. Teams that included members who had not worked together before provided less hands-on care and later initial shocks compared to teams that had trained together before exercises [ 29 ].

Transactive memory is not just important for team performance but it also boosts team morale and commitment. Michinov and colleagues [ 30 ] conducted a cross-sectional study of 193 nurses and anesthetists from eight French hospitals. The survey contained measures of transactive memory, work-team effectiveness and work attitudes. The researchers found that transactive memory positively predicted members' perceptions of team effectiveness and also affective outcomes such as team identification and job satisfaction.

Although studies of team transactive memory in organizations have focused on the benefits of member specialization, building in a certain degree of overlapping knowledge so that members can substitute for one another as necessary may be especially important for critical care teams where team membership changes on a daily basis and non-routine, time-sensitive, life-threatening decisions are commonplace.

Lesson 3: leaders' behavior matters

Team leader behavior is a well-documented contributor to team effectiveness [ 31 ]. How team leaders structure the team, define its purpose, remove organizational barriers, help individual members enhance their contributions to the team, and coach to help members use their collective resources to fulfill team goals all influence team success [ 32 ]. Additionally, team leaders are influential on an interpersonal level because their behavior is salient to team members. Members look to leaders' behaviors as an indicator of what is expected and accepted of their own behavior [ 33 ]. Thus, leader behavior shapes team climate and team capabilities. With respect to team climate, for example, research shows that leader inclusiveness - the extent to which leaders, such as physicians or nurse managers, sought and appreciated others' input, made themselves available, and displayed fallibility - predicts psychological safety. In fact, research has found that the difference in psychological safety between physicians and non-physicians is minimized in health care teams with empowering leadership [ 8 ]. In these units, psychological safety is high, as is team learning and performance [ 12 ].

Leaders who adopt an empowering leadership style share power and give more autonomy to subordinates [ 34 ]. Some of the behaviors associated with an empowering leadership style include: leading by example, informing, coaching, participative decision making and showing concern for the team [ 35 ]. In studies of management teams in a variety of organizations, an empowering leadership style has been positively associated with knowledge sharing and higher levels of team efficacy, which in turn are positively associated with team performance [ 36 ]. Empowering leadership styles have also been associated with the job satisfaction of subordinates [ 15 ]. It is important to note that many of these studies were conducted in management teams where teams were not making life and death decisions. Research on trauma resuscitation teams suggests that there may be other important contingencies for critical care teams.

Yun and colleagues [ 37 ] observed admissions, shadowed teams, and interviewed specialists in an ethnographic study of trauma resuscitation teams over a six-month period. Their findings demonstrated that the effectiveness of different leadership styles depended on the severity of the patient's condition and the level of team experience. Directive leadership was more effective when a patient was severely injured, whereas empowering leadership was more effective when a patient was not severely injured. Directive leadership was also better when a trauma team was inexperienced, but empowering leadership was better when a trauma team had high experience working together.

Although it has not been addressed in previous studies, it is quite possible that empowering leadership during patient rounds, quality improvement meetings and other routine low-stakes situations may enable critical care teams to coordinate more effectively during traumas under directive leadership. The psychological safety that develops through empowering leadership may increase the likelihood that team members will notice and speak up if they see a physician making an error during a resuscitation [ 38 ].

A clinician's synthesis

All critical care is 'high stakes'; survival and its quality depend upon optimal implementation of high-quality decisions. Some decisions can be made more deliberatively, and if errant, there is opportunity for reversibility, whereas others may cause immediate irreversible endorgan dysfunction or death. Daily rounds and bedside resuscitations are common team activities that demonstrate how intra-team relationships can be activity-specific yet highly complementary. The importance of leadership, psychological safety and transactive memory in team effectiveness becomes self-evident if we dissect these everyday activities.

High-stakes, time-to-ponder: daily care and 'unit management'

A week after finishing fellowship, I walked into 'my' ICU at a 350-bed teaching hospital. I was the unit's first intensivist, team cohesion was poor and mortality was 34% for patients whose expected mortality was 24% [ 39 ]. While I had exemplary role models, my critical care fellowship provided no formal instruction on how to lead, organize and motivate teams. Consequently, the first decade was marked by trial and (frequent) error; but I believed that the excess mortality justified 'transformation by brute force.' Despite the fact that patient outcomes improved, the first year was harrowing for my teammates. The directive style that had served me well in sports antagonized team members. Nurses and residents cried. Everyone complained. Change is 'hard,' even when implemented through gradual consensus-building, and there are easy ways and hard ways to achieve healthcare goals. I had to 'stumble onto' how to facilitate team performance.

Interdisciplinary rounds are the foundation of critical care. Stakes of the discussions and decisions are high, but there is ample time to build team skills and empowerment. I mistakenly treated other team members as 'reporters', there to provide me with information so I could make most of the decisions. While this (immature) modus operandi may be expected from a just-graduated trainee, eager to assert his new skills and directive discretion, it simultaneously disrespects and fails to leverage the talents and energies of teammates. The intensivist can not be at every bedside, every minute. She depends highly on others (especially nurses and physician extenders) to keep her apprised of substantial developments as they unfold. It is in the ICU leader's and patients' interests to have teammates who: are well trained, to distinguish between substantive versus irrelevant signal; have learned how to administer the multitude of daily, evidence-based therapies (automatically) without constant oversight and reteaching; and feel safe, empowered and prepared to speak up - during rounds or subsequently - when they see something that has not been reported to the team that they think may impact (the team's collective synthesis and thus) individual care plans or systems safety.

Strong leaders can, but they do not need to, dominate team discourse. Consensual leadership cultivates psychological safety, which in turn promotes positive transactive memories. Team rounds take a bit longer, but time is well invested because both routine and emergency care are positively impacted (see below). A number of concrete 'leadership practices,' exercised during rounds, help achieve these goals.

First, leaders should actively illicit the observations and viewpoints of others on the team (even when he thinks he knows the answer). Historic hierarchies discourage non-doctors and/or junior team members from speaking up. If a patient's bedside nurse has failed to share his/her observations or suggestions, simply ask: 'Have we missed anything?' This technique simultaneously provides psychological safety by transmitting to the individual, and all team members, that their observations/opinions are welcome ... or even expected. Transactive memory is formed that 'my perspective' matters - and so in future rounds (and emergencies; see below), non-physician team members feel more comfortable contributing their - often critical - observations.

Teaching is another important technique of promoting team spirit and psychological safety. Healthcare professionals share a heritage of self-improvement as a means to reduce human suffering. By promoting a team culture of shared inquiry and intellectual discovery, the leader demonstrates beneficence; genuine interest in the growth of teammates. Teaching must not be unilateral didacticism. All team members can be encouraged to bring their latest learning to the team for consideration. Meritorious ideas should be implemented, thereby demonstrating that good ideas (not just those of the team leader) will receive consideration and can be actualized. By cultivating rounds as a shared time/space for group learning, the democratic leader builds psychological safety and transactive memory. Both the team's interpersonal modus operandi and its ever-increasing library of shared learning and practices eventually become 'traits' - hard-wired, unconsciously, into daily activities.

Another powerful technique is to regularly name team victories and failures. Open, non-accusatory discussion of failures and errors permits us to share the negative emotions that can otherwise erode spirit and effectiveness. A particularly powerful tool is for the team-leader to choose his own mistakes - acknowledging fallibility, providing the 'safety' for others to do the same. By acknowledging that errors are part of human being, and that the only inexcusable sin is to not learn collectively from our errors, guilt can be neutralized or even 'spun' into positive experiences that cultivate willingness to self-report for systems-improvement in the future (that is, positive transactive memory). Similarly, team victories can be named and shared. When a patient, not expected to live, leaves the hospital on a path to recovery, it is not the intensivist's victory but rather the result of the team's collective effort and energy. In medical ICUs, one in five patients do not leave hospital alive, and a sizeable proportion of the remainder experience suboptimal survivorship. So it is particularly important for the team not to get discouraged, to collectively celebrate the team's promotion of 'good saves' and 'good deaths'.

Team science concepts apply equally to monthly quality assurance meetings. Representatives from each group of professionals bring concerns or new practices for consideration by the group. If consensus builds that an item requires action, processes are deconstructed and reconstructed to address the problem or install a solution. Each team member brings a different point of view to inform process engineering, champion implementation and monitor solutions.

Ultra-high stakes, no-time-to-ponder; cardiopulmonary resuscitation

On Thanksgiving Day, a young man with variceal hemorrhage was banded shortly after admission, but soon a river of blood poured from his intubated mouth. In the ensuing 2 hours, three nurses, a respiratory therapist, gastroenterologist, three residents, one fellow and I moved reflexively and simultaneously. Participating nurses' assignments were cross-covered, saline was squeezed by residents with the largest triceps, another central line was placed, another quick endoscopy failed, blood and body warmers were fetched and applied. Blood products were fetched and administered, and finally a Blakemore tube was placed. 'Thinking aloud' throughout, we shared ideas and modified the approach several times as the situation evolved. Roughly 10 units of packed cells, 5 fresh frozen plasma, 3 platelets, 10 L normal saline and 24 hours later, he was stable and not one organ system had failed. The Blakemore was deflated, repeat banding was successful, he was extubated and went home shortly thereafter. That Thanksgiving Day, without congas or fanfare, our team played 'the beautiful game'.

Each member's individual training and excellence, coupled with our team's transactive memory and psychological safety (to offer opinions that differed from mine), resulted in an optimal outcome, where he could have died that same day. Transactive memory from daily rounds and previous resuscitations were the predicate for both the coordination of efforts (that is, knowing what to do, feeling comfortable acting independently even before an order was issued) and the real-time clinical problem solving (that is, everyone in the room felt safe to speak up and offer opinions about what to do next based on accumulated, pooled experience of the team). Note that my role necessarily became more directive than during rounds - teams expect a resuscitation leader, and deliberate democratic processes are temporarily/partly suspended. This highlights that 'contingent leadership,' that is, determined by the venue or situation, is most germane to critical care. But even during emergencies and my more directive approach, nearly everyone offered suggestions that helped us synthesize and strategize. Thinking aloud in our resuscitations is a quality/safety check (in case reasoning/logic is wrong) and broadcasts to the team 'what is next', so team members can participate, prepare and better coordinate their activities.

There are insufficient data to prove that behavioral science can be applied to improve ICU outcomes [ 40 , 41 ]. Nonetheless, ICU management is, fundamentally, team-building that is teachable and learnable. Educational programs might include formal training in behavioral sciences to complement young clinicians' developing repertoire of medical science. World Cups are not won by individuals, and since teams are the sharp end of the critical care stick, it is reasonable to believe that team performance impacts patient outcomes as much or more than brilliance of any one individual team member. Trainees in critical care need not struggle for a decade after training to acquire these skills by trial and error at the expense of nurses, therapists, patients and the team.

This article is part of a series on Healthcare Delivery, edited by Dr Andre Amaral and Dr Gordon Rubenfeld .

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Manthous, C., Nembhard, I.M. & Hollingshead, A.B. Building effective critical care teams. Crit Care 15 , 307 (2011). https://doi.org/10.1186/cc10255

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Promoting Critical Thinking in Your Intensive Care Unit Team - 17/11/21

Effective and efficient critical thinking skills are necessary to engage in accurate clinical reasoning and to make appropriate clinical decisions. Teaching and promoting critical thinking skills in the intensive care unit is challenging because of the volume of data and the constant distractions of competing obligations. Understanding and acknowledging cognitive biases and their impact on clinical reasoning are necessary to promote and support critical thinking in the ICU. Active educational strategies such as concept or mechanism mapping can help to diagnose disorganized thinking and reinforce key connections and important clinical and pathophysiologic concepts, which are critical for inductive reasoning.

Keywords : Critical thinking, Clinical reasoning, Clinical decision making, Metacognition, Cognitive biases, Critical care, Medical education

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Nurses well-being in intensive care units: study of factors promoting team commitment

Affiliations.

1 Department of Public Health, Clinical and Molecular Medicine, University of Cagliari, Italy.
2 Anesthesia and Intensive Care Department, Pain Therapy Service, University of Cagliari, Italy.
PMID: 24750240
DOI: 10.1111/nicc.12083

Background: Intensive care units (ICUs) are challenging work environments because of the critical condition of patients, and ICU nurses frequently lament low job satisfaction and high staff turnover. Nevertheless, organizational and work characteristics, and the quality of relationships with staff can help to maintain nurses' enthusiasm and increase job satisfaction.

Aim: The aim of this study was to analyse how nursing work environment factors affect identification and commitment among ICU nurses.

Design: A cross-sectional study was carried out in 12 ICUs from four Italian urban hospitals.

Method: A total of 222 nurses participated and completed a self-reported questionnaire.

Results and conclusion: Results show that nursing work characteristics are directly related to team commitment, and that the nursing work characteristics and team commitment relationship was mediated by both perceived supervisor support and job satisfaction.

Relevance to clinical practice: Our findings may concretely contribute to literature and offer additional suggestions to improve nurses' work conditions and patient health in ICUs.

Keywords: Intensive care unit; Mediating role; Nurses; Nursing work characteristics; Team commitment.

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Abstract. Effective and efficient critical thinking skills are necessary to engage in accurate clinical reasoning and to make appropriate clinical decisions. Teaching and promoting critical thinking skills in the intensive care unit is challenging because of the volume of data and the constant distractions of competing obligations.
Promoting Critical Thinking in Your Intensive Care Unit Team
Critical thinking is defined as efficiently and effectively analyzing or evaluating medical in-formation to make decisions that are precise, logical, accurate, and appropriate. The intensive care unit is a dynamic and challenging environment where volume and complexity of data increases the risk of cognitive errors, morbidity, and mortality.
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Teaching and promoting critical thinking skills in the intensive care unit is challenging because of the volume of data and the constant distractions of competing obligations. Understanding and ...
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We believe these five strategies provide practical approaches for teaching critical thinking in the intensive care unit. ... This allows both the attending and the team to reflect together on how and why the diagnosis has been made. ... Educational strategies to promote clinical diagnostic reasoning. N Engl J Med. 2006; 355:2217-2225.
Promoting Critical Thinking in Your Intensive Care Unit Team
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Promoting Critical Thinking in Your Intensive Care Unit Team.
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Assessing and Developing Critical-Thinking Skills in the Intensive Care
Critical thinking helps the nurse to navigate the complex and stressful environment of the ICU. Critical thinking includes more than just nursing knowledge. It includes the ability to think through complex, multifaceted problems to anticipate needs, recognize potential and actual complications, and to expertly communicate with the team.
Assessing and Developing Critical-Thinking Skills in the Intensive Care
Critical thinking helps the nurse to navigate the complex and stressful environment of the ICU. Critical thinking includes more than just nursing knowledge. It includes the ability to think through complex, multifaceted problems to anticipate needs, recognize potential and actual complications, and to expertly communicate with the team. A nurse ...
Promoting Critical Thinking in Your Intensive Care Unit Team
Effective and efficient critical thinking skills are necessary to engage in accurate clinical reasoning and to make appropriate clinical decisions. Teaching and promoting critical thinking skills in the intensive care unit is challenging because of the volume of data and the constant distractions of competing obligations. Understanding and acknowledging cognitive biases and their impact on ...
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Intensive Care Unit Decision-Making in Uncertain and Stressful Conditions Part 2: Cognitive Errors, Debiasing Strategies, and Enhancing Critical Thinking Crit Care Clin. 2022 Jan;38(1):89-101 . doi: 10. ... and provides a framework for teaching critical thinking in the intensive care unit as a strategy to promote learner development and ...
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Read the latest articles of Critical Care Clinics at ScienceDirect.com, Elsevier's leading platform of peer-reviewed scholarly literature ... select article Promoting Critical Thinking in Your Intensive Care Unit Team. ... Review article Full text access Promoting Critical Thinking in Your Intensive Care Unit Team. Jeremy B. Richards, Richard ...
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Berg, Scoping review of critical thinking literature in healthcare education, Occup Ther Health Care, с. 1 Facione Huang, Critical thinking in health professions education: summary and consensus statements of the Millennium Conference 2011, Teach Learn Med, № 26, с. 95
A Multidisciplinary Model for Critical Thinking in the Intensive Care Unit
This webinar is focused on providing our perspective on the importance of macro cognition and team cognition in the decision-making process in healthcare settings, most notably the intensive care unit (ICU). The webinar includes live presentations by experts in the field followed by an interactive session from attendees.
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Effective and efficient critical thinking skills are necessary to engage in accurate clinical reasoning and to make appropriate clinical decisions. Teaching and promoting critical thinking skills in the intensive care unit is challenging because of the volume of data and the constant distractions of competing obligations. Understanding and acknowledging cognitive biases and their impact on ...
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We believe these five strategies provide practical approaches for teaching critical thinking in the intensive care unit. ... Proposed debiasing strategies include encouraging trainees to consider alternative diagnoses (3, 6, 27, 28) and promoting broad differentials. In particular, they need to be able to rethink cases when confronted with ...
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This narrative review describes why diagnostic errors occur by shedding additional light on systems 1 and 2 forms of thinking, reviews literature on debiasing strategies in medicine, and provides a framework for teaching critical thinking in the intensive care unit as a strategy to promote learner development and minimize cognitive failures.
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The intensive care unit (ICU) is a highly complex and fast-paced environment where patients necessitate time-sensitive management. History gathering and participation. Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI 53045, USA * Corresponding author. 8701 West Watertown Plank ...
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Critical Care Clinics - Vol. 38 - N° 1 - p. 113-127 - Promoting Critical Thinking in Your Intensive Care Unit Team - EM consulte. Rechercher Rechercher. Service Client : 01 71 16 55 99 Mes alertes; Ma bibliothèque ... Promoting Critical Thinking in Your Intensive Care Unit Team - 17/11/21.
Nurses well-being in intensive care units: study of factors promoting
Background: Intensive care units (ICUs) are challenging work environments because of the critical condition of patients, and ICU nurses frequently lament low job satisfaction and high staff turnover. Nevertheless, organizational and work characteristics, and the quality of relationships with staff can help to maintain nurses' enthusiasm and increase job satisfaction.

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