example of critical thinking in an emergency situation

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• Educational advances in emergency medicine
• Open access
• Published: 16 April 2020

How to think like an emergency care provider: a conceptual mental model for decision making in emergency care

• Nasser Hammad Al-Azri 1  

International Journal of Emergency Medicine volume  13 , Article number:  17 ( 2020 ) Cite this article

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General medicine commonly adopts a strategy based on the analytic approach utilizing the hypothetico-deductive method. Medical emergency care and education have been following similarly the same approach. However, the unique milieu and task complexity in emergency care settings pose a challenge to the analytic approach, particularly when confronted with a critically ill patient who requires immediate action. Despite having discussions in the literature addressing the unique characteristics of medical emergency care settings, there has been hardly any alternative structured mental model proposed to overcome those challenges.

This paper attempts to address a conceptual mental model for emergency care that combines both analytic as well as non-analytic methods in decision making.

The proposed model is organized in an alphabetical mnemonic, A–H. The proposed model includes eight steps for approaching emergency cases, viz., awareness, basic supportive measures, control of potential threats, diagnostics, emergency care, follow-up, groups of particular interest, and highlights. These steps might be utilized to organize and prioritize the management of emergency patients.

Metacognition is very important to develop practicable mental models in practice. The proposed model is flexible and takes into consideration the dynamicity of emergency cases. It also combines both analytic and non-analytic skills in medical education and practice.

Combining various clinical reasoning provides better opportunity, particularly for trainees and novices, to develop their experience and learn new skills. This mental model could be also of help for seasoned practitioners in their teaching, audits, and review of emergency cases.

“It is one thing to practice medicine in an emergency department; it is quite another to practice emergency medicine. The effective practice of emergency medicine requires an approach, a way of thinking that differs from other medical specialties” [ 1 ]. Yet, common teaching trains future emergency practitioners to “practice medicine in an emergency department.”

Emergency care is a complex activity. Emergency practitioners are like circus performers who have to “spin stacks of plates, one on top of another, of all different shapes and weights” [ 2 ]. This can be further complicated by simultaneous demands from various and multiple stakeholders such as administrators, patients, and colleagues. Add to that the time-bound interventions and parallel tasks required and it can be thought of no less than being chaotic.

There is a tendency to distinguish emergency care from other medical practices as being more action-driven than thought-oriented [ 3 ]. This probably stems from the presumption that emergency medicine follows the same strategy as other medical disciplines so it is judged within the same parameters. Another explanation for this is that emergency practitioners are seen to act immediately on their patients when other medical specialties might take longer time preparing for this action. However, the chaotic environment is different and it requires complex decision-making skills and strategies. Unlike general medical settings, in EM, often a history is unobtainable, and a physical examination and medical investigations are not readily available in a critically ill patient. Despite this, emergency medicine is still being taught using the conceptual model of general medicine that follows an information-gathering approach seeking optimal decision-making. In medical decision-making, the commonly adopted hypothetico-deductive method involving history taking, physical examination, and investigations corresponds to the general approach of medicine.

Importance of rethinking existing medical emergency care mental model

Education in medical emergency care adopts a strategy similar to that of general medicine despite the fact that it is not optimal in emergency departments. Emergency care providers cannot anticipate what condition their patients will be in and they cannot follow the steps of detailed history taking, complete physical examination, ordering required investigations, and, using the results, plan the management of their patient. Classical clinical decision theory may not fit dynamic environments like emergency care. Patients in the emergency department are usually critical, time is limited, and information is scarce or even absent, and decisions are still urgently required.

Croskerry (2002) has noted: “In few other workplace settings, and in no other area of medicine, is decision density as high” [ 4 ] as in emergency medicine. In an area where an information gap can be found in one third of emergency department visits, and more so in critical cases [ 5 ], an information-seeking strategy is unlikely to succeed. Moreover, diagnostic closure is usually the short-term target in the hypothetico-deductive method while this is less of a concern in emergency care. Instead, the short-term priorities in emergency care include assessment of acuity and life-saving [ 6 ]. Figure 1 presents a comparison of the conventional general medicine decision-making approach and how emergency care setting differs relatively with regard to those basic characteristics.

Comparing conventional decision-making in general medicine vs. emergency care setting

Hence, a different mental model with a distinctive approach for emergency care is required. Mental models are important to describe, explain, and predict situations [ 7 ]. This is the roadmap through the wilderness of emergency care rather than a guide on driving techniques. Experts are differentiated from novices in several aspects: sorting and categorizing problems, using different reasoning processes, developing mental models, and organizing content knowledge better [ 8 ]. In addition, experienced physicians form more rapid, higher quality working hypotheses and plans of management than novices do. Novices are especially challenged in this area, since teaching general problem solving was replaced with problem-based learning, as the emphasis shifted toward “helping students acquire a functional organization of content with clinically usable schemas” [ 9 ]. The proposed model is intended to better organize the knowledge and approach required in emergency care, which may eventually help improve the practice, particularly of novices.

Clinical decision-making in emergency care requires a unique approach that is sensitive to the distinctive milieu where emergency care takes place [ 10 ]. Xiao et al. (1996) have identified four components of task complexity in emergency medical care [ 11 ]. These include multiple and concurrent tasks, uncertainty, changing plans of management, and compressed work procedures with high workload. Such complex components require an approach that accommodates such factors and balances the various needs in a timely and priority-based, situationally adaptable methodology.

A different model for emergency care

This article addresses a general mental approach involving eight steps arranged with an initialism mnemonic, A–H. Figure 2 presents an infographic of the lifecycle of this A–H decision-making process. These steps represent the lifecycle of decision-making in emergency practice and form the core of the proposed conceptual model. Every emergency care encounter starts with the first step of situational awareness (A) where the provider starts to build up a workable mental template of the case presentation. This process is ongoing throughout the encounter to reflect the dynamic nature of emergency cases. The second to fourth steps (B–D) involve a triaging process in order to prioritize the most appropriate management at that point in time, through a series of risk-stratification stages. Then, additional emergency management (E) follows based on the flow of the case from earlier steps. Following emergency management, a planning step regarding further care (F) for the patient is required. The following step concerns emergency patients who may represent special high risk groups (G) with special precautions and particular diagnostic and management approaches to be considered. This step is, in fact, a mandate throughout the process but included here as a reminder. The final step is a reflection of the entire process that highlights (H) the learning aspects from the case management. Throughout the process, the first and last steps are ongoing as they reflect the dynamicity of the situation.

Situational decision-making model lifecycle

A: (awareness, situational)

It is likely that the first thought of an emergency care provider, when confronted with an acutely ill patient, is the issue of time: “how much time do I have to act and how much time do I have to think?” [ 12 ]. The mental brainstorming that takes place in a matter of seconds is a very valuable and indispensable part of every single emergency encounter. Providers’ prior beliefs, expectations, emotions, knowledge, skills, and experience all contribute to the initial approach adopted. Individuals vary in the importance they attach to different factors [ 13 ], and this variation is reflected in the decisions they make. The importance of this mental process is, unfortunately, not reflected in either general medicine or emergency medicine education and research. Traditionally, “medical education has focused on the content rather than the process of clinical decision making” [ 6 ].

The notion of “situational awareness” (SA) is a useful concept to borrow from aviation sciences. Situational awareness has been defined as the individual’s “perception of the elements of the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future” [ 14 ]. As noted from the definition, SA tries to amalgamate the experiences and background of the practitioner with the current situation in order to enable a more educated prediction of what will happen next. Although the concept originated outside of the medical field, it has already been utilized in several medical disciplines including surgery, anesthesiology, as well as quality care, and patient safety [ 15 , 16 , 17 ]. Moreover, SA has been discussed in several emergency care mandates and it is recommended for inclusion in the non-technical skills training of teams in acute medicine [ 15 ].

This emphasizes that an attentiveness to the dynamic nature of priorities in emergency management is as important as knowledge and skills. As such, SA provides a mental model that encourages emergency care practitioners to stay alert for changes in the surrounding environment and relate those changes to case management. The importance of this step in the model is that it prods us to go beyond our immediate perceptions and gut feelings and develop an overall view of the situation [ 18 ]. Practically, decision-making in emergency care has historically depended more on rapid situational assessment rather than optimal decision-making strategies as in the hypothetico-deductive method [ 19 ]. SA is probably one of the most neglected, yet distinguishing, skills in emergency medicine education.

B: (basic life, organ, and limb supportive measures)

The second step in emergency decision-making involves a clinical triaging process. The purpose of this triage is to prioritize time-bound interventions or treatment for the patient. Immediate risks to life, organs, or limbs take priority in case management. This precedes any analytical thinking provided by detailed history taking, physical examination, or investigations, even though a focused approach might be necessary. This step maintains the dynamicity of the process of decision-making and allows the practitioner a holistic view of available and appropriate options rather than ordinary linear thinking. It also provides flexibility of movement between treatment options in response to dynamic changes in the condition.

Life-threatening conditions always take precedence in emergency management. The next priority is to manage immediate risks to body organs or limbs; this is the essence of medical emergency management. Therefore, the aim of this step on basic supportive action (B) is to save the vitals of the patient. This is where advanced cardiac and trauma life support algorithms and emergency management protocols are important.

A useful approach at this step is pattern recognition. In real practice, when confronted with a critically ill or crashing patient, the emergency care provider usually abandons the time-consuming hypothetico-deductive method; pattern recognition offers a rapid assessment and clinical plan that permits immediate life-, organ-, or limb-saving measures to take place [ 20 ]. Pattern recognition, known also as non-analytic reasoning, is a central feature of the expert medical practitioner’s ability to rapidly diagnose and respond appropriately, compared to novices who struggle with linear thinking skills [ 21 , 22 , 23 ]. This approach could be further augmented by the availability of algorithms and protocols that allow immediacy of perception and initiation of management [ 4 ], as well as by including it in clinical teaching and education.

C: (control potential life, organ, and limb threats)

While emergency care providers must prioritize immediate threats to life, organs, and limbs, they must also anticipate and recognize imminent threats to the same and control them (C). This is one of the biggest challenges in emergency care compared to other medical settings; oftentimes, the grey cases are the hidden tigers. In fact, seasoned emergency care providers know that even the most unremarkable patients may have a catastrophic outcome within moments [ 24 ]. Emergency care providers usually adopt mental templates for the top diagnoses that they need to exclude for every particular presentation. This is a step of “ruling out” worst diagnoses before proceeding. Croskerry (2002) asserts that this “rule out the worst case” strategy is almost pathognomonic of decision-making in the emergency department [ 4 ]. Many emergency presentations (e.g., poisoning, head injury, and chest pain) are true time bombs that any emergency care provider should be alert to.

This step presents an intermediate stage between the previous step (B) where pattern recognition and non-analytic reasoning dominates decision-making, and the next step (D) where the hypothetico-deductive approach with its analytic reasoning starts to play a major role in decision-making. As such, this step utilizes a mixture of the analytic and non-analytic reasoning to aid emergency care practitioners the “rule out the worst case” scenario in their patients. Examples of presentation-wise “worst case” scenarios are illustrated in Table 1 .

Once a potential threat is discovered, the practitioner will be situationally more aware and this will help to initiate measures that could prevent further deterioration of the condition. Again, this step is another that is practiced commonly by expert practitioners but is presented informally or insufficiently in emergency medicine training or education. Emergency care practitioners should focus more on this step due to its centrality in emergency care practice as well as its importance for ensuring safety of patients.

D: (diagnostics)

Once immediate and/ or imminent threats have either been excluded or managed, the emergency care provider may move on to the next step of formulating a workable clinical diagnosis (D) through the commonly adopted hypothetico-deductive medical model via a focused history taking, physical examination, and investigations. This is basically what all medical students are trained for in their undergraduate and postgraduate medical education. This step involves the utilization of existing tools for optimal decision-making within the available resources in the emergency department. Nevertheless, a final diagnosis may not be reachable in the emergency department setting.

E: (emergency management)

This is the step that naturally follows the diagnostic step (D). After collecting appropriate information regarding patient presentation through a focused history, examination and investigations, the emergency care provider may start emergency management and treatment as indicated. This does not contradict utilizing appropriate interventions in earlier steps (B, C) that aim to save life, organs, or limbs.

F: (further care)

While decisions about intervention(s) in emergency care are very difficult, often decisions about the further management of the patient are just as difficult [ 25 ]. Grey cases present the dilemma of whether to admit, keep for observation, or discharge. This decision is problematic because it entails not only technical aspects of the clinical status of the patient but also social, political, economic, and administrative factors along with the availability of supportive resources.

The initial brainstorm regarding imminent threats to life, organs, and limbs (C) continues to play a major role in the emergency provider’s decision-making. Discharging patients to their home carries risks related to a lack of clinical care and formal monitoring compared to admitted patients [ 26 ]. Hence, this step is pivotal in the emergency care of patients with significant implications in terms of outcome. Incorporating this step in the model is essential for the emergency care provider to have an integrative and holistic view of the case.

G: (groups of particular interest)

Certain groups of patients warrant particular concern while being managed in emergency care settings [ 27 ]. There are different reasons to consider these groups as high risk. Often, it is because they have underlying pathologies and/or physiologies that make them more prone for complications, acute exacerbations, and/or they are less likely to withstand the stress of acute illness. These groups include the elderly, pregnant women, children, psychiatric patients, and patients with a significant past medical history. These patients should cause particular concern that may justify a different and/or altered path of management at any step during the emergency care process.

H: (highlights)

Lack of informative feedback is one of the major drawbacks in emergency medicine that hinders learning and maintaining of cognitive and practical emergency care skills [ 28 ]. Feedback and highlighting of learning points is a crucial step in medical education and can be done in a variety of methods [ 29 ]. This is an ongoing step that starts at the case encounter and never ends during a practitioner’s career. Here, the practitioner reflects on the care and management provided during the encounter and makes a case for learning and advancing his knowledge, skills, and attitudes in emergency care. This step is usually done unconsciously. However, exposing this process to scrutiny and making it a formal step in the process of emergency care is likely to enhance experiential learning of the provider and, more importantly, offer feedback for the first step in the model that further augments situational awareness (A). This will add to the reservoir of understanding and attentiveness for future cases.

Thinking about thinking, also called metacognition, in emergency care is likely to reveal the strengths and weaknesses in current approaches and open doors for further development and improvement of emergency care. It is also likely to aid in recognizing opportunities for interventional thinking strategies [ 18 ]. This could be a step forward in preparing a broad-based, critical thinking pattern for physicians, who may save lives, organs, and limbs based on undifferentiated cases without having to depend on a diagnosis to do so.

The presented conceptual model attempts to contribute to the exposition and development of the forgotten skill of clinical reasoning with a particular reference to emergency and acute care. Moreover, it dissects the usually overlooked process of decision-making in emergency care [ 28 ]. The arrangement of the model components in alphabetical mnemonics may act as a reminder of a decision process that will reduce omission errors in clinical settings. Furthermore, functional categorization of the steps involved in decision-making, as well as in actual practice, will provide and develop further insight and awareness of cognitive strengths and weaknesses at different stages.

A significant advantage of the proposed conceptual mental model for emergency care is that it combines both analytic as well as non-analytic (also called naturalistic decision-making, NDM) strategies to aid medical emergency management. This model does not eliminate the need for the hypothetico-deductive analytic method but rather incorporates it within a more comprehensive approach and utilizes it when it is situationally appropriate along with the non-analytic method (Fig. 3 ). Combining different clinical reasoning strategies helps novice practitioners have greater diagnostic accuracy, improve performance, and avoid giving misleading information [ 30 , 31 ].

Situationally combined analytical and non-analytical decision-making methods

In addition, emergency care has been described as chaotic. Chaotic contexts are characterized by dominance of the unknowables, indeterminate relationships between the cause and effect, and a lack of existing manageable patterns [ 32 ]. In such contexts, the best approach to management is to act to establish order, then sense where stability is present and where it is not, and then respond to transform the situation from chaos to complexity [ 32 ]. The described model addresses those activities in order where the emergency care provider first acts (B), then senses (C), and finally responds (D, E) to establish a more stable context.

The suggested approach can be utilized by various groups of practitioners, such as physicians, nurses, and paramedics, hence the use of the term emergency care. Moreover, novices and trainees learn better by being exposed to the decision-making process involved, rather than just mimicking the actions of experts [ 3 ].

Medical education is required to produce a “broad-based physician, geared to solving undifferentiated clinical problems” [ 33 ]. Emergency medicine, as a generalist discipline, has probably high potential for that. The presented model could be used in several contexts. It could be used as a mental model that guides the practice of emergency care for novice practitioners or it could be used as a teaching tool for medical students and trainees, in not only emergency care, but also other specialties that may have exposure to emergency cases. In addition to novice providers, it has implications for physicians in emergency departments, paramedics in emergency medical services, general practitioners in rural clinics, nurse practitioners, or anyone else practicing emergency care. This may lead to the development of training and educational methods that suit each stage separately, as well as recognizing cognitive biases and avoiding them.

The model may also be used for audits and reviews of emergency case management, including self-audits, departmental or institutional audits, or peer reviews. Moreover, clinical decision-making aids could be further developed and tailored to the needs of the practice. For example, algorithms and pattern recognition are suitable for steps B and C teaching and decision-making, while event-driven and hypothetico-deductive approaches are more suitable for step D. This model is very broad-based. It is hoped that this conceptual model will help practitioners develop a more focused approach, a broader perspective, and a better ability to detect critical signals when managing undifferentiated emergency cases.

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Al-Azri, N.H. How to think like an emergency care provider: a conceptual mental model for decision making in emergency care. Int J Emerg Med 13 , 17 (2020). https://doi.org/10.1186/s12245-020-00274-0

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Decision Making in Emergency Medicine: We can’t escape bias

The human mind is imperfect. We all make mistakes. We are all susceptible to bias. Although we love to talk about and perform procedures, emergency medicine is really all about making difficult decisions, and so we all need a thorough understanding of how our minds work, how mistakes are made, and hopefully how to avoid them. ( There is a prior 4 part series on the topic that can be found here. )Through learning about the various cognitive biases, and identifying some strategies to mitigate common errors, the hope is that we will be able to avoid future mistakes. For that reason, I was thrilled to be invited to take part in the writing of a textbook called “Decision Making in Emergency Medicine” . In each chapter, we discuss a different bias, show it in practice through multiple clinical scenarios, and discuss possible mitigating factors. Although we will never be able to completely avoid error, I think this textbook is essential reading for any emergency clinician.

Decision making in emergency medicine by Manda Raz and Pourya Pourahya (Eds)

The publishers of the book have been kind enough to allow me to share a couple of the chapters I wrote for the book to give you a taste of what it is trying to accomplish. This is the introduction I wrote entitled “we can’t escape bias”, which covers some limitations of cognitive theory in medicine:

We can’t escape bias

As this book clearly demonstrates, the human mind is imperfect. We all make mistakes. We are all susceptible to bias. Through learning about the various cognitive biases, and identifying some strategies to mitigate common errors, the hope is that readers will be able to avoid future mistakes. Unfortunately, there are limitations to the application of cognitive theory in medicine. Even armed with the wealth of knowledge provided by this book, we will still make mistakes.

It is unlikely that we will ever completely eliminate medical error. The decisions we make are incredibly complex, and the human mind is inherently fallible. Integrating what we know about cognitive theory and psychology into medicine is a logical step forward, but there are significant limitations, both theoretical and practical, to the application of cognitive theory in medicine. This chapter explores some of those limitations. 

Theoretical problems

An assumption that underlies much of this book is that, although the human mind is fallible, it also has the tools to self-correct. This is often explained in terms of dual process theory. Most of our thinking is rapid, unconscious, and intuitive – system 1 thinking. However, system 1 thinking is also prone to bias. Luckily, we are also capable of slower, contemplative, analytical thought – system 2 thinking. Most proposed solutions for biased thinking involve recognizing faulty type 1 thinking, and shifting to the presumably more accurate type 2 thinking. 

This simple blueprint may be misleading. Type 1 thinking is not always bad and type 2 thinking is not always better. In fact, especially when it comes to experts like physicians, it isn’t clear that thinking is so easily dichotomized. The clean distinction between type 1 and type 2 thinking is based largely on studies of undergraduate students, usually performing tasks in which they lack expertise, and so it isn’t clear that these results are applicable to expert medical decision making. 

The heuristics employed in type 1 thinking are efficient mental strategies that help us deal with uncertainty and ambiguity. Experts often use heuristics very effectively. In fact, in some scenarios, heuristics may lead to better decisions than analytical thinking. (Croskerry 2005; Eva 2005; Monteiro 2013) Discussions about cognitive biases tend to overemphasize the harms of using heuristics, while ignoring their many benefits. In medical emergencies, the speed of (well trained) type 1 thinking is almost certainly more important than the accuracy of formal analytic thought. Although it occasionally fails, it is important to recognize that type 1 thinking is not inherently bad. (Tverysky 1974; Norman 2010; Dhaliwhal 2017) 

Similarly, although analytic thought results in more accurate decisions in some settings, it is by no means infallible. In fact, conscious reasoning can sometimes produce worse results, because type 2 thinking puts a heavy load on working memory, which has significant limitations. (Norman 2010) Furthermore, many of the described cognitive biases also impair type 2 thinking. For example, premature closure and confirmation bias are both phenomena that arise during data gathering and synthesis, and are therefore more likely to be associated with type 2 thinking. (Norman 2010; Norman 2017)

A final and significant problem for dual process theory is the poorly defined interface between systems 1 and 2. How exactly is one supposed to effectively and consistently transition from type 1 to type 2 thinking? System 1 is generally described as always active, rapidly sorting through the avalanche of available data. Meanwhile, system 2 is described as monitoring system 1 and making corrections as necessary. However, it is not clear how that monitoring happens. What triggers the transition from system 1 to system 2? The act of monitoring would seem to require rapid analysis and pattern recognition to identify possible errors. Thus, the monitoring of system 1 sounds like a system 1 process, which presumably would also be prone to errors. 

If we want to correct errors we need to be able to recognize those errors. Strategies to mitigate cognitive errors are based on the major assumption that we have active control over our decision making processes. They assume that, in the moment, we will be able to recognize that our thinking is biased and flip from non-analytical to analytical thinking. Unfortunately, there is little evidence that this process occurs reliably. (Eva 2005)

It seems like a simple task – we recognize errors in other people’s thinking all the time. However, the blind spot bias tells us that we have a much harder time identifying our own biases. In fact, a core paradox of cognitive theory is that you cannot know that you are wrong. While in the midst of making a mistake, being wrong feels exactly like being right. (Dhaliwhal 2017) Thus, although we can recognize past errors, there is actually no mechanism that alerts us that we are currently wrong. 

Much like understanding the concept of a visual blind spot does not eliminate the blindness, simply understanding the existence of cognitive biases does not prevent them from occurring. In fact, Daniel Kakneman (the Nobel Prize winning originator of dual process theory) says that after 30 years of study, although he can more readily recognize errors in others, he isn’t sure that he is any better at avoiding these biases himself. (Kahneman 2011)

Biases are often more complex than we make them seem

Individual biases are generally more complex than we initially realize. We tend to talk about biases as dichotomous. We either committed an error or we didn’t; our thinking was either biased or it wasn’t. However, much of the research describes behaviour that falls into a grey area between those two extremes. 

For example, although the original research on base rate neglect involved participants completely ignoring the base rate, further research has made it clear that the base rate is often considered, and errors, when they occur, mostly arise from not fully adjusting for the base rate, rather than completely ignoring it. Furthermore, the extent of the error is significantly influenced by the specifics of the scenario, and many “biased” results can be explained by rational thinking that simply conflicts with researcher expectations. (Klayman 1995; Koehler 2010)

The majority of the research establishing cognitive biases was performed in carefully controlled laboratory settings, usually with college undergraduates as the subjects. This is important, because there is evidence that experience can reduce or eliminate biased thinking. For example, athletes demonstrate much better statistical intuition when a problem is presented using a sporting example, as compared to when the same problem is presented in a less familiar context. (Nisbett 1983). Similarly, a classic puzzle used to demonstrate confirmation bias involves asking participants to prove the rule “if a card has a vowel on one side, it has an odd number on the other side.” In this abstract, non-intuitive example, people frequently demonstrate confirmation bias. However, if you present people with the exact same problem using a real world example (“prove that if a person is drinking beer, that person must be over 18 years of age”), participants perform almost perfectly. (Klayman 1995) Therefore, we should not automatically assume that the biases described in laboratory settings generalize to expert clinicians. (Norman 2017)

Studies in medicine are (thus far) underwhelming

The true incidence and impact of cognitive biases in medicine is unknown. The evidence is incomplete and imperfect. According to one meta-analysis, the majority of studies looking at cognitive bias in medicine did not take place in real clinical scenarios, but instead employed paper based or simulated vignettes, often done by trainees, and therefore may not generalize well to clinical practice. (Saposnik 2016) Studies that have attempted to examine bias in clinical settings have generally been retrospective, and focused on known misdiagnoses rather than all clinical decisions. Therefore, the results will be skewed by significant hindsight bias and selection bias.

Attempting to classify medical bias retrospectively is fraught with problems. When assessing cases, experts frequently disagree about which biases might be present. When looking at the same case, experts are twice as likely to identify biases if they are told the clinician chose the wrong diagnosis, a clear indication of hindsight bias. (Zwaan 2017) Similarly, whether or not physicians believe an error has occurred is heavily influenced by the patient outcome. (Caplan 1991)

There seems to be a general consensus in medicine that diagnostic errors are more likely to result from cognitive errors than knowledge deficits. However, the evidence for this claim is somewhat unconvincing. The most frequently cited study – a survey by Graber and colleagues (2005) – is a retrospective analysis of 100 cases of known diagnostic error. They state that knowledge deficits were only involved in 4 cases, whereas faulty synthesis of data (such as premature closure) was involved in the vast majority. However, it is almost impossible to distinguish premature closure from a scenario in which a diagnosis was not considered because it was unknown to the clinician, or because a known disease presented in an unknown way (in other words, from a knowledge deficit). In fact, knowledge deficits (whether medical or statistical) could explain a lot of decisions that appear to be affected by bias. Thus, knowledge deficits may be an underestimated cause of diagnostic error. (Norman 2010) Furthermore, addressing knowledge deficits the best technique we currently have to improve medical decision making. 

That being said, considering the sheer number of decisions we make in medicine, and the large number of possible biases, it is likely that these biases play an important role in medical error. Assuming that our decisions are impacted by these biases, the more important questions are how and if we can prevent these errors. 

Unfortunately, the evidence that biases can be mitigated in medicine is mixed, with the bulk of the trials showing no benefit. There are a few trials that demonstrate improved diagnostic accuracy from traineses on paper based vignettes when more time is taken for reflection. (Mamede 2008; Hess 2015) However, Sherbino and colleagues (2012) actually demonstrated more errors when trainees were instructed to slow down and be thorough, and numerous other studies have demonstrated no difference in accuracy between clinicians instructed to work rapidly and those instructed to work slowly and thoroughly. (Ilgen 2011; Ilgen 2013; Norman 2014; Monteiro 2015) 

Three studies looked at educational interventions designed to improve diagnostic thinking by educating students about cognitive biases (meta-cognition). Another study attempted to used a cognitive debiasing checklist, with questions such as “did I consider the inherent flaws of heuristic thinking?” None of these interventions have resulted in improved accuracy. (Sherbino 2011; Shimizu 2013; Sherbino 2014; Smith 2015)

Considering the potential extent of the problem, there has been relatively little research into potential solutions. The failures thus far are a sobering reminder of the complexity of human cognition. We should probably be skeptical of overly simplistic solutions. Our training as medical experts spans many years, and our training in critical thinking (whether formal or informal) started many years before that. It is doubtful that simple instructions to “think about our thinking” will be enough to change the momentum of our ingrained strategies.

However, I don’t think these early failures should dissuade us. You wouldn’t decide that a child has no musical ability after only a month of piano lessons, but our early attempts at teaching cognitive debiasing look a lot more like that month than 10,000 hours of deliberate practice. We need more research, and we need to find ways to train doctors to use their cognitive resources efficiently and effectively.

Recognizing potential harms

Although improving medical decision making seems like a clear win, I think it is important to consider the potential harms of applying cognitive theory in medicine. The most obvious harm is opportunity cost. Thus far, there is no evidence that cognitive debiasing techniques improve decision making or patient outcomes. Time is a precious resource in medicine. If cognitive theory does not improve outcomes, the time and effort required to create curricula, teach, and learn this new material could better used elsewhere.

Likewise, in eschewing rapid heuristics and promoting slow analytic thought, debiasing techniques are likely to make the practice of medicine less efficient. This inefficiency would be worthwhile if it translates into better decisions. However, to date there is no evidence that these debiasing techniques are effective, so the inefficiency is just inefficient. In a worst case scenario, attempts to use slower analytic thinking in medical emergencies could result in delays to critical interventions and bad patient outcomes.

Attempts to avoid cognitive biases could also result in substantial costs. Confirmation bias tells us to focus on ruling out alternatives, rather than searching for confirmatory evidence. However, there are always numerous potential alternative diagnoses. If the solution to confirmation bias is understood as requiring tests to rule out each of those alternatives, the result could be significant increases in testing, costs, and harms to our patients. 

A more subtle harm is the potential for attempts at debiasing to actually increase error. Many of the described biases exist at opposite ends of a spectrum. Avoiding one may cause us to necessarily commit the other. For example, the chapter on base rate neglect reminds us to consider the base rate whenever we make diagnostic decisions. Rare conditions are rare, and shouldn’t be pursued frequently. However, in avoiding the workup of rare conditions, we are falling into another cognitive bias: the zebra retreat. Rare conditions, although rare, do happen, so need to be worked up. The solution to one bias necessarily leads us towards another. 

Although there seems to be little doubt that cognitive biases play some role in medical error, the extent of their impact is not clear. Most importantly, it isn’t clear if these biases can be prevented, and if so, how. Thus far, attempts to mitigate cognitive biases through educational programs in medicine have mostly failed, although the research has been quite limited thus far. It is also important to acknowledge that many of the processes described as biases are really heuristics that are frequently used to efficiently and accurately arrive at a correct diagnosis. When attempting to improve our cognition, we need to be careful not to throw the baby out with the bathwater. 

How should the practicing clinician proceed? As we are used to with most scientific reviews, the conclusion is: more research is needed. I am reassured by evidence that more experienced physicians are less prone to bias than trainees. (Feltovich 1984) It is likely that we can teach ourselves to be more effective thinkers, but we are a long way from understanding the full impact of these biases on medical practice, and more importantly the techniques that may help prevent them. In the meantime, astute clinicians will endeavour to learn about these biases, attempt to identify specific areas of cognitive reasoning that might be improved, and, most of all, remain humble in their clinical reasoning. 

Caplan RA, Posner KL, Cheney FW (1991) Effect of outcome on physicians’ judgments of appropriateness of care. JAMA 265:1957–1960.

Croskerry P (2005) Diagnostic Failure: A Cognitive and Affective Approach. In: Henriksen K, Battles JB, Marks ES, Lewin DI, eds. Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb.

Dhaliwal G. Premature closure? Not so fast (2017) BMJ Qual Saf 26(2):87-89.

Eva KW, Norman GR (2005) Heuristics and biases – a biased perspective on clinical reasoning. Med Educ 39(9):870-872.

Feltovitch PJ, Johnson P E, Moller JH, Swanson DB (1984) The role and development of medical knowledge in diagnostic expertise. In W. Clancey & E. H.

Graber ML (2005) Diagnostic error in internal medicine. Arch Int Med 165:1493–9.

Hess BJ, Lipner RS, Thompson V, et al (2015) Blink or think: can further reflection improve initial diagnostic impressions? Acad Med 90:112–18.

Ilgen JS, Bowen JL, Yarris LM, Fu R, Lowe RA, Eva K (2011) Adjusting our lens: Can developmental differences in diagnostic reasoning be harnessed to improve health professional and trainee assessment? Acad Emerg Med 18(suppl 2):S79–S86.

Ilgen JS, Bowen JL, McIntyre LA, et al. (2013) Comparing diagnostic performance and the utility of clinical vignette-based assessment under testing conditions designed to encourage either automatic or analytic thought. Acad Med 88:1545–1551.

Kahneman, D (2011) Thinking, fast and slow. New York, NY, US: Farrar, Straus and Giroux.

Klayman J (1995) Varieties of Confirmation Bias. Psychology of Learning and Motivation 32:385-418.

Koehler JJ (2010)The base rate fallacy reconsidered: Descriptive, normative, and methodological challenges. Behav Brain Sci 19(1):1-17.

Mamede S, Schmidt HG, Rikers RM, Penaforte JC, Coelho-Filho JM (2008) Influence of perceived difficulty of cases on physicians’ diagnostic reasoning. Acad Med 83:1210–1216.

Monteiro SM, Norman G (2013) Diagnostic Reasoning: Where We’ve Been, Where We’re Going. Teaching and Learning in Medicine 25(sup1):S26-S32.

Monteiro SD, Sherbino JD, Ilgen JS, et al (2015) Disrupting diagnostic reasoning: Dointerruptions, instructions, and experience affect the diagnostic accuracy and response time of residents and emergency physicians? Acad Med 90:511–517.

Nisbett RE, Krantz DH, Jepson C, Kunda Z (1983) The use of statistics in everyday inductive reasoning. Psychological Review 90:339-363.

Norman G, Sherbino J, Dore K (2014) The etiology of diagnostic errors: A controlled trial of system 1 versus system 2 reasoning. Acad Med 89:277–284.

Norman GR, Eva KW (2010) Diagnostic error and clinical reasoning. Medical Education 44(1):94-100.

Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S (2017) The Causes of Errors in Clinical Reasoning. Academic Medicine 92(1):23-30.

Saposnik G, Redelmeier D, Ruff CC, Tobler PN (2016) Cognitive biases associated with medical decisions: a systematic review. BMC Med Inform Decis Mak 16(1):138.

Sherbino J, Yip S, Dore KL, Siu E, Norman GR (2011)The effectiveness of cognitive forcing strategies to decrease diagnostic error: An exploratory study. Teach Learn Med 23:78–84.

Sherbino J, Dore KL, Wood TJ, et al (2012) The relationship between response time and diagnostic accuracy. Acad Med 87:785–791.

Sherbino J, Kulasegaram K, Howey E, Norman G (2014) Ineffectiveness of cognitive forcing strategies to reduce biases in diagnostic reasoning: A controlled trial. CJEM 16:34–40.

Shimizu T, Matsumoto K, Tokuda Y (2013) Effects of the use of differential diagnosis checklist and general de-biasing checklist on diagnostic performance in comparison to intuitive diagnosis. Med Teach 35:e1218–e1229.

Smith BW, Slack MB (2015) The effect of cognitive debiasing training among family medicine residents. Diagnosis 2:117–121.

Tversky A, Kahneman D (1974) Judgment under Uncertainty: Heuristics and Biases. Science 185(4157):1124-1131.

Zwaan L, Monteiro S, Sherbino J, Ilgen J, Howey B, Norman G. (2017) Is bias in the eye of the beholder? A vignette study to assess recognition of cognitive biases in clinical case workups. BMJ Qual Saf. 26(2):104-110.

Cite as: Morgenstern, J. We can’t escape bias. In Raz M, Pouryahya P (Eds). Decision Making in Emergency Medicine . Singapore. Springer Singapore; 2021.

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Justin Morgenstern

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3 thoughts on “ decision making in emergency medicine: we can’t escape bias ”.

• 3 comments

Thanks. We wrote a piece on that. https://www.researchgate.net/publication/353580368_Decision_making_in_emergency_medicine_Balance_between_intuition_and_bias

I am so excited to read this book!

We expand on these points in the Second Ed of the ABC of Clinical Reasoning (Wiley, 2022) – biases have been misunderstood in medical education, knowledge plays a key role … but a) what do we mean by “knowledge” and b) there are still things to do with the *way* we think that lead (or not) to error. https://www.wiley.com/en-ie/ABC+of+Clinical+Reasoning,+2nd+Edition-p-9781119871538

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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills.

Images sourced from Getty Images

Related Resources

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?

CLINICAL PRACTICE

Emergency Room Triage: How ER Nurses Prioritize Patient Care

• Last Updated: 08/06/2023

In the chaotic and fast-paced environment of an emergency room, the role of the nurse is crucial in providing efficient and effective care to patients. Emergency room triage is the process in which nurses prioritize patient care based on the severity of their condition. It is a skill that requires quick thinking, sharp assessment abilities, and the ability to make critical decisions under pressure.

In this article, we will delve into the fascinating world of emergency room triage and explore the strategies and techniques that ER nurses employ to ensure that patients receive the care they need in a timely manner. From determining priority levels using the Emergency Severity Index (ESI) to handling the emotional and physical demands of their role, ER nurses are unsung heroes who play a vital role in saving lives.

Join us as we unravel the intricate workings of emergency room triage and gain a deeper appreciation for the dedicated professionals who make it all possible.

The Role of ER Nurses in Triage

Emergency room nurses are the backbone of triage. They are the first point of contact for patients as they enter the emergency room, and their role is to quickly assess the severity of each patient’s condition. ER nurses are trained to handle a wide range of medical emergencies, from minor injuries to life-threatening situations. They play a critical role in determining the order in which patients are seen by the medical team, ensuring that those in the most urgent need of care receive it promptly.

ER nurses must possess excellent communication skills , as they need to gather vital information from patients and their families to make informed decisions about their care. They must also be able to remain calm and composed in high-stress situations, as they often encounter patients in extreme pain or distress.

The Importance of Prioritizing Patient Care in the ER

In the emergency room, time is of the essence. Every second counts when it comes to saving lives and preventing further deterioration of a patient’s condition. This is where the importance of prioritizing patient care comes into play. By efficiently triaging patients, ER nurses are able to identify those who require immediate attention and prioritize their care accordingly. By doing so, they can ensure that critical interventions are initiated promptly, potentially preventing further complications or even death.

Prioritizing patient care also helps to streamline the flow of patients in the emergency room, reducing wait times and improving overall efficiency. ER nurses are trained to quickly assess patients, recognizing signs and symptoms that indicate a need for urgent intervention.

Their ability to prioritize effectively is a testament to their expertise and dedication to providing the best possible care to every patient who comes through the doors of the emergency room.

The Triage Process in Emergency Rooms

The triage process is a systematic approach to evaluating and categorizing patients based on the severity of their condition. It involves a series of assessments, including gathering information about the patient’s chief complaint, vital signs, and medical history. The information gathered during triage helps nurses determine the order in which patients should be seen by the medical team.

The triage process follows a set of guidelines and protocols, ensuring consistency and fairness in determining priority levels. One commonly used tool in emergency room triage is the Emergency Severity Index (ESI). The ESI is a five-level scale that helps nurses categorize patients based on the acuity of their condition, ranging from level 1 (most urgent) to level 5 (least urgent). This standardized approach to triage allows for efficient and effective patient management, helping to ensure that those in the most critical condition receive immediate attention.

Key Factors Considered in Triaging Patients

When triaging patients, ER nurses take into consideration several key factors to determine the severity of their condition. These factors include the patient’s vital signs, such as heart rate, blood pressure, respiratory rate, and oxygen saturation levels. Nurses also assess the patient’s level of pain or distress, as well as any signs of respiratory distress , altered mental status, or potential life-threatening conditions. The patient’s medical history, including any pre-existing conditions or allergies, is also taken into account.

ER nurses use their clinical judgment and knowledge to evaluate the overall picture and make an informed decision about the patient’s priority level. It is a delicate balancing act, as they must consider not only the acuity of the patient’s condition but also the availability of resources and the needs of other patients in the emergency room.

Triage Categories and Their Significance

In emergency room triage, patients are categorized into different levels of acuity based on the severity of their condition. These categories help guide the order in which patients are seen by the medical team.

The exact categories may vary depending on the hospital or healthcare facility, but generally, they include:

Level 1: Resuscitation

Patients in this category require immediate life-saving interventions. They may be in cardiac arrest, experiencing severe trauma, or have life-threatening conditions that require immediate attention.

Level 2: Emergent

Patients in this category have potentially life-threatening conditions that require urgent intervention. They may be experiencing severe pain, have difficulty breathing, or have injuries that require immediate attention.

Level 3: Urgent

Patients in this category have conditions that are not immediately life-threatening but require prompt medical attention. They may have moderate pain, acute illnesses, or injuries that require timely intervention.

Level 4: Semi-Urgent

Patients in this category have conditions that are not immediately life-threatening and can be managed within a reasonable timeframe. They may have minor injuries, non-acute illnesses, or chronic conditions that require medical attention.

Level 5: Non-urgent

Patients in this category have conditions that are not life-threatening and can be managed with minimal intervention. They may have minor injuries or non-acute illnesses that can be treated in a primary care setting.

Challenges Faced by ER Nurses in Triage

Emergency room triage is a high-pressure environment that comes with its own set of challenges. ER nurses must be able to make quick decisions, often with limited information, and under stressful conditions. They must be able to prioritize effectively, balancing the needs of multiple patients simultaneously.

ER nurses also face the challenge of managing the emotional and physical demands of their role. They often encounter patients who are in extreme pain or distress, and they must be able to provide compassionate care while remaining focused on the task at hand.

ER nurses also work long hours, often in high-stress situations, which can take a toll on their well-being. Despite these challenges, ER nurses rise to the occasion every day, providing the best possible care to their patients and ensuring that those in the most critical condition receive the attention they need.

Best Practices for Effective Triage in the Emergency Room

Effective triage in the emergency room requires a combination of technical skills, critical thinking, and effective communication.

Here are some best practices that ER nurses follow to ensure that patients receive the care they need in a timely manner:

• Rapid assessment : ER nurses are trained to quickly assess patients upon arrival, gathering vital information and identifying any signs or symptoms that require immediate attention.
• Clear communication : ER nurses must effectively communicate with patients, their families, and the medical team to ensure that everyone is on the same page regarding the patient’s condition and needs.
• Prioritization : ER nurses must be able to prioritize effectively, taking into account the acuity of the patient’s condition, available resources, and the needs of other patients in the emergency room.
• Adapting to change : In the emergency room, situations can change rapidly. ER nurses must be able to adapt to these changes and make quick decisions to provide the best possible care to their patients.
• Collaboration : ER nurses work closely with the entire healthcare team, including doctors, technicians, and other nurses. Collaboration and effective teamwork are essential for providing seamless patient care in the emergency room.

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Two Examples of How I Used Critical Thinking to Care for my Patient (Real Life Nursing Stories) | NURSING.com

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Critical Thinking on the Nursing Floor

Critical thinking can seem like such an abstract term that you don’t practically use. However, this could not be farther from the truth. Critical thinking is frequently used in nursing. Let me give you a few examples from my career in which critical thinking helped me take better care of my patient.

The truth is, that as nurses we can’t escape critical thinking . . . I know you hate the word . . . but let me show you how it actually works!

Critical Thinking in Nursing: Example 1

I had a patient that was scheduled to go to get a pacemaker placed at 0900. The physician wanted the patient to get 2 units of blood before going downstairs for the procedure. I administered it per protocol. About 30 minutes after that second unit got started, I noticed his oxygen went from 95% down to 92% down to 90%. I put 2L of O2 on him and it came up to 91%. But it just sort of hung around the low 90s on oxygen.

I stopped. And thought. What the heck is going on?

I looked at his history. Congestive heart failure.

I looked at his intake and output. He was positive 1.5 liters.

I thought about how he’s got extra fluid in general, and because of his CHF, he can’t really pump out the fluid he already has, let alone this additional fluid. Maybe I should listen to his lungs..

His lungs were clear earlier. I heard crackles throughout both lungs.

OK, so he’s got extra fluid that he can’t get out of his body. What do I know that will get rid of extra fluid and make him pee? Maybe some Lasix?

I ran over my thought process with a coworker before calling the doc. They agreed. I called the doc and before I could suggest anything, he said “Give him 20 mg IV Lasix one time, and I’ll put the order in.” CLICK.

I gave the Lasix. He peed like a racehorse (and was NOT happy with me for making that happen!). And he was off of oxygen before he went down to get his pacemaker.

Badda Bing Bada Boom!

Critical Thinking in Nursing: Example 2

My patient just had her right leg amputated above her knee. She was on a Dilaudid PCA and still complaining of awful pain. She maxed it out every time, still saying she was in horrible pain. She told the doctor when he rounded that morning that the meds weren’t doing anything. He added some oral opioids as well and wrote an order that it was okay for me to give both the oral and PCA dosings, with the goal of weaning off PCA.

“How am I going to do that?” I thought. She kept requiring more and more meds and I’m supposed to someone wean her off?

I asked her to describe her pain. She said it felt like nerve pain. Deep burning and tingling. She said the pain meds would just knock her out and she’d sleep for a little while but wake up in even worse pain. She was at the end of her rope.

I thought about nerve pain. I thought about other patients that report similar pain. Diabetics with neuropathy would talk about similar pain… “What did they do for it? ” I thought. Then I remembered that many of my patients with diabetic neuropathy were taking gabapentin daily for pain.

“So if this works for their nerve pain, could it work for a patient who has had an amputation?” I thought.

I called the PA for the surgeon and asked them what they thought about trying something like gabapentin for her pain after I described my patient’s type of pain and thought process.

“That’s a really good idea, Kati. I’ll write for it and we’ll see if we can get her off the opioids sooner. ”

She wrote for it. I gave it. It takes a few days to really kick in and once it did, the patient’s pain and discomfort were significantly reduced. She said to get rid of those other pain meds because they “didn’t do a damn thing,” and to “just give her that nerve pain pill because it’s the only thing that works”.

And that we did!

She was able to work with therapy more because her pain was tolerable and was finally able to get rest.

What the HELL is Critical Thinking . . . and Why Should I Care?

What your nursing professor won’t tell you about critical thinking .

by Ashely Adkins RN BSN

When I started nursing school, I remember thinking,   “how in the world am I going to remember all of this information, let alone be able to apply it and critically think?”   You are not alone if you feel like your critical thinking skills need a little bit of polishing.

Let’s step back for a moment, and take a walk down memory lane. It was my first semester of nursing school and I was sitting in my Fundamentals of Nursing course. We were learning about vital signs, assessments, labs, etc. Feeling overwhelmed with all of this new information (when are you   not   overwhelmed in nursing school?), I let my mind wonder to a low place…

Am I really cut out for this? Can I really do this? How can I possibly retain all of this information?  Do they really expect me to remember everything AND critically think at the same time?

One of my first-semester nursing professors said something to me that has stuck with me throughout my nursing years. It went a little something like this:

“Critical thinking does not develop overnight . It takes time. You don’t learn to talk overnight or walk overnight. You don’t   learn to critically think overnight .”

My professor was absolutely right.

As my journey throughout nursing school, and eventually on to being a “real nurse” continued, my critical thinking skills began to BLOSSOM. With every class, lecture, clinical shift, lab, and simulation, my critical thinking skills grew.

You may ask…how?

Well, let me tell you…

• Questioning

These are the key ingredients to growing your critical thinking skills.

Time.   Critical thinking takes time. As I mentioned before, you do not learn how to critically think overnight. It is important to set   realistic   expectations for yourself both in nursing school and in other aspects of your life.

Exposure.   It is next to impossible to critically think if you have never been exposed to something. How would you ever learn to talk if no one ever talked to you? The same thing applies to nursing and critical thinking.

Over time, your exposure to new materials and situations will cause you to think and ask yourself, “why?”

This leads me to my next point.   Questioning.   Do not be afraid to ask yourself…

“Why is this happening?”

“Why do I take a blood pressure and heart rate before I give a beta-blocker?”

“Why is it important to listen to a patient’s lung sounds before and after they receive a blood transfusion?”

It is important to constantly question yourself. Let your mind process your questions, and discover answers.

Confidence.   We always hear the phrase, “confidence is key!” And as cheesy as that phrase may be, it really holds true. So many times, we often times sell ourselves short.

YOU KNOW MORE THAN YOU THINK YOU KNOW.

In case you did not catch it the first time…

Be confident in your knowledge, because trust me, it is there. It may be hiding in one single neuron in the back of your brain, but it is there.

It is impossible to know everything. Even experienced nurses do not know everything.

And if they tell you that they do…they are wrong!

The   key   to critical thinking is   not about knowing everything ; It is about   how you respond when you do not know something .

How do you reason through a problem you do not know the answer to? Do you give up? Or do you persevere until you discover the answer?

If you are a nursing student preparing for the NCLEX, you know that the NCLEX   loves   critical thinking questions. NRSNG has some great tips and advice on   critical thinking when it comes to taking the NCLEX .

There are so many pieces to the puzzle when it comes to nursing, and it is normal to feel overwhelmed. The beauty of nursing is when all of those puzzle pieces come together to form a beautiful picture.

That is critical thinking.

Critical thinking is something you’ll do every day as a nurse and honestly, you probably do it in your regular non-nurse life as well. It’s basically stopping, looking at a situation, identifying a solution, and trying it out. Critical thinking in nursing is just that but in a clinical setting.

We’ve written a MASSIVE lesson on Care Plans and Critical Thinking :

Mastering The COPD Nursing Care Plan in Just 10 Minutes!

Renal Failure Pt Care

4 "real world" examples of using clinical judgement to figure out what to do first as a nurse | nursing.com, 12 study tips for how to study for pharmacology in nursing school | nursing.com, similar blog posts.

Critical Thinking and Nursing Care Plans Go Together Like Chicken and Waffles | NURSING.com

Patients We Will Never Forget | NURSING.com

Stress Overload Nursing Diagnosis and Care Plan | NURSING.com

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How to think like an emergency care provider: a conceptual mental model for decision making in emergency care

Nasser hammad al-azri.

Emergency Department, Ibri Hospital, Ministry of Health, POB 134, 516 Akhdar, Ibri, Oman

Associated Data

General medicine commonly adopts a strategy based on the analytic approach utilizing the hypothetico-deductive method. Medical emergency care and education have been following similarly the same approach. However, the unique milieu and task complexity in emergency care settings pose a challenge to the analytic approach, particularly when confronted with a critically ill patient who requires immediate action. Despite having discussions in the literature addressing the unique characteristics of medical emergency care settings, there has been hardly any alternative structured mental model proposed to overcome those challenges.

This paper attempts to address a conceptual mental model for emergency care that combines both analytic as well as non-analytic methods in decision making.

The proposed model is organized in an alphabetical mnemonic, A–H. The proposed model includes eight steps for approaching emergency cases, viz., awareness, basic supportive measures, control of potential threats, diagnostics, emergency care, follow-up, groups of particular interest, and highlights. These steps might be utilized to organize and prioritize the management of emergency patients.

Metacognition is very important to develop practicable mental models in practice. The proposed model is flexible and takes into consideration the dynamicity of emergency cases. It also combines both analytic and non-analytic skills in medical education and practice.

Combining various clinical reasoning provides better opportunity, particularly for trainees and novices, to develop their experience and learn new skills. This mental model could be also of help for seasoned practitioners in their teaching, audits, and review of emergency cases.

“It is one thing to practice medicine in an emergency department; it is quite another to practice emergency medicine. The effective practice of emergency medicine requires an approach, a way of thinking that differs from other medical specialties” [ 1 ]. Yet, common teaching trains future emergency practitioners to “practice medicine in an emergency department.”

Emergency care is a complex activity. Emergency practitioners are like circus performers who have to “spin stacks of plates, one on top of another, of all different shapes and weights” [ 2 ]. This can be further complicated by simultaneous demands from various and multiple stakeholders such as administrators, patients, and colleagues. Add to that the time-bound interventions and parallel tasks required and it can be thought of no less than being chaotic.

There is a tendency to distinguish emergency care from other medical practices as being more action-driven than thought-oriented [ 3 ]. This probably stems from the presumption that emergency medicine follows the same strategy as other medical disciplines so it is judged within the same parameters. Another explanation for this is that emergency practitioners are seen to act immediately on their patients when other medical specialties might take longer time preparing for this action. However, the chaotic environment is different and it requires complex decision-making skills and strategies. Unlike general medical settings, in EM, often a history is unobtainable, and a physical examination and medical investigations are not readily available in a critically ill patient. Despite this, emergency medicine is still being taught using the conceptual model of general medicine that follows an information-gathering approach seeking optimal decision-making. In medical decision-making, the commonly adopted hypothetico-deductive method involving history taking, physical examination, and investigations corresponds to the general approach of medicine.

Importance of rethinking existing medical emergency care mental model

Education in medical emergency care adopts a strategy similar to that of general medicine despite the fact that it is not optimal in emergency departments. Emergency care providers cannot anticipate what condition their patients will be in and they cannot follow the steps of detailed history taking, complete physical examination, ordering required investigations, and, using the results, plan the management of their patient. Classical clinical decision theory may not fit dynamic environments like emergency care. Patients in the emergency department are usually critical, time is limited, and information is scarce or even absent, and decisions are still urgently required.

Croskerry (2002) has noted: “In few other workplace settings, and in no other area of medicine, is decision density as high” [ 4 ] as in emergency medicine. In an area where an information gap can be found in one third of emergency department visits, and more so in critical cases [ 5 ], an information-seeking strategy is unlikely to succeed. Moreover, diagnostic closure is usually the short-term target in the hypothetico-deductive method while this is less of a concern in emergency care. Instead, the short-term priorities in emergency care include assessment of acuity and life-saving [ 6 ]. Figure ​ Figure1 1 presents a comparison of the conventional general medicine decision-making approach and how emergency care setting differs relatively with regard to those basic characteristics.

Comparing conventional decision-making in general medicine vs. emergency care setting

Hence, a different mental model with a distinctive approach for emergency care is required. Mental models are important to describe, explain, and predict situations [ 7 ]. This is the roadmap through the wilderness of emergency care rather than a guide on driving techniques. Experts are differentiated from novices in several aspects: sorting and categorizing problems, using different reasoning processes, developing mental models, and organizing content knowledge better [ 8 ]. In addition, experienced physicians form more rapid, higher quality working hypotheses and plans of management than novices do. Novices are especially challenged in this area, since teaching general problem solving was replaced with problem-based learning, as the emphasis shifted toward “helping students acquire a functional organization of content with clinically usable schemas” [ 9 ]. The proposed model is intended to better organize the knowledge and approach required in emergency care, which may eventually help improve the practice, particularly of novices.

Clinical decision-making in emergency care requires a unique approach that is sensitive to the distinctive milieu where emergency care takes place [ 10 ]. Xiao et al. (1996) have identified four components of task complexity in emergency medical care [ 11 ]. These include multiple and concurrent tasks, uncertainty, changing plans of management, and compressed work procedures with high workload. Such complex components require an approach that accommodates such factors and balances the various needs in a timely and priority-based, situationally adaptable methodology.

A different model for emergency care

This article addresses a general mental approach involving eight steps arranged with an initialism mnemonic, A–H. Figure ​ Figure2 2 presents an infographic of the lifecycle of this A–H decision-making process. These steps represent the lifecycle of decision-making in emergency practice and form the core of the proposed conceptual model. Every emergency care encounter starts with the first step of situational awareness (A) where the provider starts to build up a workable mental template of the case presentation. This process is ongoing throughout the encounter to reflect the dynamic nature of emergency cases. The second to fourth steps (B–D) involve a triaging process in order to prioritize the most appropriate management at that point in time, through a series of risk-stratification stages. Then, additional emergency management (E) follows based on the flow of the case from earlier steps. Following emergency management, a planning step regarding further care (F) for the patient is required. The following step concerns emergency patients who may represent special high risk groups (G) with special precautions and particular diagnostic and management approaches to be considered. This step is, in fact, a mandate throughout the process but included here as a reminder. The final step is a reflection of the entire process that highlights (H) the learning aspects from the case management. Throughout the process, the first and last steps are ongoing as they reflect the dynamicity of the situation.

Situational decision-making model lifecycle

A: (awareness, situational)

It is likely that the first thought of an emergency care provider, when confronted with an acutely ill patient, is the issue of time: “how much time do I have to act and how much time do I have to think?” [ 12 ]. The mental brainstorming that takes place in a matter of seconds is a very valuable and indispensable part of every single emergency encounter. Providers’ prior beliefs, expectations, emotions, knowledge, skills, and experience all contribute to the initial approach adopted. Individuals vary in the importance they attach to different factors [ 13 ], and this variation is reflected in the decisions they make. The importance of this mental process is, unfortunately, not reflected in either general medicine or emergency medicine education and research. Traditionally, “medical education has focused on the content rather than the process of clinical decision making” [ 6 ].

The notion of “situational awareness” (SA) is a useful concept to borrow from aviation sciences. Situational awareness has been defined as the individual’s “perception of the elements of the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future” [ 14 ]. As noted from the definition, SA tries to amalgamate the experiences and background of the practitioner with the current situation in order to enable a more educated prediction of what will happen next. Although the concept originated outside of the medical field, it has already been utilized in several medical disciplines including surgery, anesthesiology, as well as quality care, and patient safety [ 15 – 17 ]. Moreover, SA has been discussed in several emergency care mandates and it is recommended for inclusion in the non-technical skills training of teams in acute medicine [ 15 ].

This emphasizes that an attentiveness to the dynamic nature of priorities in emergency management is as important as knowledge and skills. As such, SA provides a mental model that encourages emergency care practitioners to stay alert for changes in the surrounding environment and relate those changes to case management. The importance of this step in the model is that it prods us to go beyond our immediate perceptions and gut feelings and develop an overall view of the situation [ 18 ]. Practically, decision-making in emergency care has historically depended more on rapid situational assessment rather than optimal decision-making strategies as in the hypothetico-deductive method [ 19 ]. SA is probably one of the most neglected, yet distinguishing, skills in emergency medicine education.

B: (basic life, organ, and limb supportive measures)

The second step in emergency decision-making involves a clinical triaging process. The purpose of this triage is to prioritize time-bound interventions or treatment for the patient. Immediate risks to life, organs, or limbs take priority in case management. This precedes any analytical thinking provided by detailed history taking, physical examination, or investigations, even though a focused approach might be necessary. This step maintains the dynamicity of the process of decision-making and allows the practitioner a holistic view of available and appropriate options rather than ordinary linear thinking. It also provides flexibility of movement between treatment options in response to dynamic changes in the condition.

Life-threatening conditions always take precedence in emergency management. The next priority is to manage immediate risks to body organs or limbs; this is the essence of medical emergency management. Therefore, the aim of this step on basic supportive action (B) is to save the vitals of the patient. This is where advanced cardiac and trauma life support algorithms and emergency management protocols are important.

A useful approach at this step is pattern recognition. In real practice, when confronted with a critically ill or crashing patient, the emergency care provider usually abandons the time-consuming hypothetico-deductive method; pattern recognition offers a rapid assessment and clinical plan that permits immediate life-, organ-, or limb-saving measures to take place [ 20 ]. Pattern recognition, known also as non-analytic reasoning, is a central feature of the expert medical practitioner’s ability to rapidly diagnose and respond appropriately, compared to novices who struggle with linear thinking skills [ 21 – 23 ]. This approach could be further augmented by the availability of algorithms and protocols that allow immediacy of perception and initiation of management [ 4 ], as well as by including it in clinical teaching and education.

C: (control potential life, organ, and limb threats)

While emergency care providers must prioritize immediate threats to life, organs, and limbs, they must also anticipate and recognize imminent threats to the same and control them (C). This is one of the biggest challenges in emergency care compared to other medical settings; oftentimes, the grey cases are the hidden tigers. In fact, seasoned emergency care providers know that even the most unremarkable patients may have a catastrophic outcome within moments [ 24 ]. Emergency care providers usually adopt mental templates for the top diagnoses that they need to exclude for every particular presentation. This is a step of “ruling out” worst diagnoses before proceeding. Croskerry (2002) asserts that this “rule out the worst case” strategy is almost pathognomonic of decision-making in the emergency department [ 4 ]. Many emergency presentations (e.g., poisoning, head injury, and chest pain) are true time bombs that any emergency care provider should be alert to.

This step presents an intermediate stage between the previous step (B) where pattern recognition and non-analytic reasoning dominates decision-making, and the next step (D) where the hypothetico-deductive approach with its analytic reasoning starts to play a major role in decision-making. As such, this step utilizes a mixture of the analytic and non-analytic reasoning to aid emergency care practitioners the “rule out the worst case” scenario in their patients. Examples of presentation-wise “worst case” scenarios are illustrated in Table ​ Table1 1 .

Examples of presentation-wise “worst case” scenarios

Once a potential threat is discovered, the practitioner will be situationally more aware and this will help to initiate measures that could prevent further deterioration of the condition. Again, this step is another that is practiced commonly by expert practitioners but is presented informally or insufficiently in emergency medicine training or education. Emergency care practitioners should focus more on this step due to its centrality in emergency care practice as well as its importance for ensuring safety of patients.

D: (diagnostics)

Once immediate and/ or imminent threats have either been excluded or managed, the emergency care provider may move on to the next step of formulating a workable clinical diagnosis (D) through the commonly adopted hypothetico-deductive medical model via a focused history taking, physical examination, and investigations. This is basically what all medical students are trained for in their undergraduate and postgraduate medical education. This step involves the utilization of existing tools for optimal decision-making within the available resources in the emergency department. Nevertheless, a final diagnosis may not be reachable in the emergency department setting.

E: (emergency management)

This is the step that naturally follows the diagnostic step (D). After collecting appropriate information regarding patient presentation through a focused history, examination and investigations, the emergency care provider may start emergency management and treatment as indicated. This does not contradict utilizing appropriate interventions in earlier steps (B, C) that aim to save life, organs, or limbs.

F: (further care)

While decisions about intervention(s) in emergency care are very difficult, often decisions about the further management of the patient are just as difficult [ 25 ]. Grey cases present the dilemma of whether to admit, keep for observation, or discharge. This decision is problematic because it entails not only technical aspects of the clinical status of the patient but also social, political, economic, and administrative factors along with the availability of supportive resources.

The initial brainstorm regarding imminent threats to life, organs, and limbs (C) continues to play a major role in the emergency provider’s decision-making. Discharging patients to their home carries risks related to a lack of clinical care and formal monitoring compared to admitted patients [ 26 ]. Hence, this step is pivotal in the emergency care of patients with significant implications in terms of outcome. Incorporating this step in the model is essential for the emergency care provider to have an integrative and holistic view of the case.

G: (groups of particular interest)

Certain groups of patients warrant particular concern while being managed in emergency care settings [ 27 ]. There are different reasons to consider these groups as high risk. Often, it is because they have underlying pathologies and/or physiologies that make them more prone for complications, acute exacerbations, and/or they are less likely to withstand the stress of acute illness. These groups include the elderly, pregnant women, children, psychiatric patients, and patients with a significant past medical history. These patients should cause particular concern that may justify a different and/or altered path of management at any step during the emergency care process.

H: (highlights)

Lack of informative feedback is one of the major drawbacks in emergency medicine that hinders learning and maintaining of cognitive and practical emergency care skills [ 28 ]. Feedback and highlighting of learning points is a crucial step in medical education and can be done in a variety of methods [ 29 ]. This is an ongoing step that starts at the case encounter and never ends during a practitioner’s career. Here, the practitioner reflects on the care and management provided during the encounter and makes a case for learning and advancing his knowledge, skills, and attitudes in emergency care. This step is usually done unconsciously. However, exposing this process to scrutiny and making it a formal step in the process of emergency care is likely to enhance experiential learning of the provider and, more importantly, offer feedback for the first step in the model that further augments situational awareness (A). This will add to the reservoir of understanding and attentiveness for future cases.

Thinking about thinking, also called metacognition, in emergency care is likely to reveal the strengths and weaknesses in current approaches and open doors for further development and improvement of emergency care. It is also likely to aid in recognizing opportunities for interventional thinking strategies [ 18 ]. This could be a step forward in preparing a broad-based, critical thinking pattern for physicians, who may save lives, organs, and limbs based on undifferentiated cases without having to depend on a diagnosis to do so.

The presented conceptual model attempts to contribute to the exposition and development of the forgotten skill of clinical reasoning with a particular reference to emergency and acute care. Moreover, it dissects the usually overlooked process of decision-making in emergency care [ 28 ]. The arrangement of the model components in alphabetical mnemonics may act as a reminder of a decision process that will reduce omission errors in clinical settings. Furthermore, functional categorization of the steps involved in decision-making, as well as in actual practice, will provide and develop further insight and awareness of cognitive strengths and weaknesses at different stages.

A significant advantage of the proposed conceptual mental model for emergency care is that it combines both analytic as well as non-analytic (also called naturalistic decision-making, NDM) strategies to aid medical emergency management. This model does not eliminate the need for the hypothetico-deductive analytic method but rather incorporates it within a more comprehensive approach and utilizes it when it is situationally appropriate along with the non-analytic method (Fig. ​ (Fig.3). 3 ). Combining different clinical reasoning strategies helps novice practitioners have greater diagnostic accuracy, improve performance, and avoid giving misleading information [ 30 , 31 ].

Situationally combined analytical and non-analytical decision-making methods

In addition, emergency care has been described as chaotic. Chaotic contexts are characterized by dominance of the unknowables, indeterminate relationships between the cause and effect, and a lack of existing manageable patterns [ 32 ]. In such contexts, the best approach to management is to act to establish order, then sense where stability is present and where it is not, and then respond to transform the situation from chaos to complexity [ 32 ]. The described model addresses those activities in order where the emergency care provider first acts (B), then senses (C), and finally responds (D, E) to establish a more stable context.

The suggested approach can be utilized by various groups of practitioners, such as physicians, nurses, and paramedics, hence the use of the term emergency care. Moreover, novices and trainees learn better by being exposed to the decision-making process involved, rather than just mimicking the actions of experts [ 3 ].

Medical education is required to produce a “broad-based physician, geared to solving undifferentiated clinical problems” [ 33 ]. Emergency medicine, as a generalist discipline, has probably high potential for that. The presented model could be used in several contexts. It could be used as a mental model that guides the practice of emergency care for novice practitioners or it could be used as a teaching tool for medical students and trainees, in not only emergency care, but also other specialties that may have exposure to emergency cases. In addition to novice providers, it has implications for physicians in emergency departments, paramedics in emergency medical services, general practitioners in rural clinics, nurse practitioners, or anyone else practicing emergency care. This may lead to the development of training and educational methods that suit each stage separately, as well as recognizing cognitive biases and avoiding them.

The model may also be used for audits and reviews of emergency case management, including self-audits, departmental or institutional audits, or peer reviews. Moreover, clinical decision-making aids could be further developed and tailored to the needs of the practice. For example, algorithms and pattern recognition are suitable for steps B and C teaching and decision-making, while event-driven and hypothetico-deductive approaches are more suitable for step D. This model is very broad-based. It is hoped that this conceptual model will help practitioners develop a more focused approach, a broader perspective, and a better ability to detect critical signals when managing undifferentiated emergency cases.

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The importance of critical thinking skills in disaster management

Affiliation.

• 1 Center for Emergency Preparedness and Disaster Response, Yale New Haven Health, 1 Church Street, 5th Floor, New Haven CT 06510, USA.
• PMID: 30670134

The adverse circumstances occasioned by disasters rarely remain static but rather continue to evolve, temporally and spatially, rendering preplanned response operations uncertain, at best, and ineffectual, at worst. As such, disaster management professionals need to think critically to implement response strategies best suited to the circumstances at hand, with the best available information. This paper provides an overview of critical thinking, and its importance in helping leaders provide order to the chaos often associated with disaster response and recovery efforts. Critical thinking skills include the ability to identify and define a problem, recognise assumptions, evaluate arguments, and apply inductive and deductive reasoning to draw conclusions from the available information. Understanding and improving a leader's critical thinking skills helps to provide a sense of confidence, trust and authority during a community-wide crisis. As such, emergency management professionals must continually enhance their critical thinking skills.

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This is Your Brain on Emergencies

There’s a fire in your building. Your plane is about to crash. A woman beside you on the street suddenly collapses.

What do you do?

Well, that depends. Every one of us is at risk for these kinds of unexpected intrusions into our day-to-day lives. What you do about it depends on whether or not you’re prepared – not just physically, but also mentally.

In any situation, some things are likely to be out of your control: the size of the fire; who’s flying the plane; what’s wrong with the woman. Some things, however, are up to you. Being aware of how you might react can go a long way toward making a bad situation better.

Know thyself

In a crisis, your brain is going to want to make decisions, and not always the best ones. The good news is there are steps you can take to be a better decision-maker in emergencies. There is science behind the way people react to stressful situations, and we can use it to our advantage.

Science tells us that people behave in high stress incidents in certain ways. What you do will be dependent in large part on what your stress level is. If your heart rate soars above about 175 beats per minute, you’re more likely to go into shutdown mode and not be able to think clearly or act. A technique called “combat breathing” (inhale through your nose, hold, exhale through your mouth, hold) has been shown to reduce your heart rate by 20-30 beats per minute. Controlling your emotion and stress level will help as you go through the decision-making process.

During the decision-making process, your mind will most likely move through three stages:

• Deliberation
• Decisive action

Knowing these stages – and preparing for them ahead of time – can help you recognize and deal with what’s going on around you more effectively.

Denial: This is not happening

Have you ever heard gunfire in your neighborhood and blamed it on a firecracker? That’s denial. And it’s perfectly normal. We don’t want to believe bad things are happening. We don’t want to panic or look silly.

In emergencies, we often look to people around us for cues about what we should do. (Is everyone else running and screaming, or are they sitting quietly in their chairs? Are others stopping to help?) This is known as social proof. Social proof is a psychological phenomenon that happens whenever people aren’t sure what to do. We assume others around us know more about the situation, and so we do what they do, whether it’s the right thing or not.

We also know that a person is less likely to take responsibility when others are present. We assume that other people are responsible for taking action, or that they’ve already done so. This is called diffusion of responsibility , and it means you’re actually more likely to get help when you’re with a single person than when you’re in a large group of people.

We are all susceptible to believing these things, which make it easy to deny that 1) an emergency is really happening, or 2) we need to do something about it.

Deliberation: What are my options?

Once you’ve recognized the emergency, you’ll begin to consider your options. If you’re smart, you’ve already started this process before the emergency happens. Maybe you participated in a fire drill at work, or you counted exactly how many rows there are between you and the emergency exit on the plane, or you took a first aid class in your community. The more you’ve prepared, the more options you’ll have to work with.

One thing you can do to prepare everywhere you go is called scripting . All it requires is a little bit of imagination. Pay attention to your surroundings and see what’s available to you. Check for exits (and consider windows as possible exits). Be nosy, especially when it concerns your safety. Then run different scenarios in your head. Where would you go if you had to get out? Who would you call if you needed help? What will you do if there’s a fire? A robbery? A bomb threat? Think about the possibilities ahead of time.

Everybody hates the idea that we practice for emergency events. Fire drills… ugh. But it’s practice, and practice helps you understand what to do or how to react when you don’t have a lot of time. Not only can practice save your life, but if you know how to save yourself, emergency responders on the scene can use their time and effort to save others. You’re one less person who needs saving, and that saves lives.

Decisive action: It’s go time!

You’ve acknowledged there’s a problem. You’ve considered your options. The next step is to take decisive action. With all the information you have, what are you going to do next?

Before you take action:

• Calm yourself
• Shift your emotion. If you do get mad, use that anger as energy.
• Stay fit – if you’re more fit, you’re likely to be more rational

Now is the time to put your plans into motion. Go to the exit, call for help, take cover, give CPR… whatever you’ve decided to do.

In most crisis situations, there is no definite right or wrong. There is no perfect way – only the best we can do. The most important thing is to do something . In almost every case, an imperfect plan is better than no plan, and action is better than inaction.

Remember, if you depend on everyone else to take care of you, you’re leaving the most important person out. Don’t wait to make a plan. Know yourself, know your situation, and be prepared to save your own life.

References and Resources

• Advanced Law Enforcement Rapid Response Training, Texas State University, Civilian Response To An Active Shooter Event (CRASE).  
• Ripley, Amanda (2008).  The Unthinkable: Who Survives When Disaster Strikes And Why. New York. Three Rivers Press.
• Video: “A Perfect Stranger”  (FEMA)
• Video: The Bystander Effect
• Podcast: Stress Response

8 comments on “This is Your Brain on Emergencies”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy » .

Thank you – this is a good topic for us to discuss in our safety meetings.

Has there ever been a link established between physical fitness and rationality?

A great primer for preparedness: mentally.

This was worth a read, I learned something!

Very informative, thank YOU! – human being is fragile and how important is to get knowledge in how to act in case of an emergency.

This is a great topic. It should definitely be taught and reinforced in medical facilities, but in schools and in work settings. Even though I know that practice and repetition instill in our brains what to do in different situations, it is often annoying practicing for the situation. The article hits it on the head. Yea it is not something we want to do, but if we want to be prepared, and be able to save lives we must practice what to do in the event of a crisis.

Thanks for sharing this topic….

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• Research article
• Open access
• Published: 01 July 2020

Emotions and feelings in critical and emergency caring situations: a qualitative study

• María F. Jiménez-Herrera   ORCID: orcid.org/0000-0003-2599-3742 1 ,
• Mireia Llauradó-Serra 2 ,
• Sagrario Acebedo-Urdiales 1 ,
• Leticia Bazo-Hernández 1 ,
• Isabel Font-Jiménez 1 &
• Christer Axelsson 3  

BMC Nursing volume  19 , Article number:  60 ( 2020 ) Cite this article

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Moral emotions are a key element of our human morals. Emotions play an important role in the caring process. Decision-making and assessment in emergency situations are complex and they frequently result in different emotions and feelings among health-care professionals.

The study had qualitative deductive design based on content analysis. Individual interviews and focus groups were conducted with sixteen participants.

The emerging category “emotions and feelings in caring” has been analysed according to Haidt, considering that moral emotions include the subcategories of “Condemning emotions”, “Self-conscious emotions”, “Suffering emotions” and “Praising emotions”. Within these subcategories, we found that the feelings that nurses experienced when ethical conflicts arose in emergency situations were related to caring and decisions associated with it, even when they had experienced situations in which they believed they could have helped the patient differently, but the conditions at the time did not permit it and they felt that the ethical conflicts in clinical practice created a large degree of anxiety and moral stress. The nurses felt that caring, as seen from a nursing perspective, has a sensitive dimension that goes beyond the patient’s own healing and, when this dimension is in conflict with the environment, it has a dehumanising effect. Positive feelings and satisfaction are created when nurses feel that care has met its objectives and that there has been an appropriate response to the needs.

Conclusions

Moral emotions can help nurses to recognise situations that allow them to promote changes in the care of patients in extreme situations. They can also be the starting point for personal and professional growth and an evolution towards person-centred care.

Peer Review reports

Nurses in the current health-care environment are confronted by complex situations arising from the conflicting values and beliefs of other health-care professionals. In these circumstances, moral emotions arise from different feelings related to not being able to ensure the best interests of the patient and relatives. Understanding why and how moral emotions arise may help nurses to develop the caring process and make it visible to all health-care professionals. Our theory is that, if nurses are aware of their moral emotions, this will help them to cope in different situations and improve nursing practice.

Definition of emotion

Emotions play an important role in the caring process, but there is still a shortage of articles relating nursing to emotions. Learning more about emotions is a key component in the nursing profession. The concept of emotion has multiple definitions. The lack of a definition is a constant source of numerous misunderstandings and a series of mostly fruitless debates between different disciplines [ 1 ]. In this report, we use the definition formulated by Scherer, Schorr and Johnstone in which they define emotions as an episode of interrelated, synchronised changes in all or some of the five organismic subsystems when responding to an external or internal event of concern. These five components are the cognitive system (what you think), the subjective process (how you interpret), the action tendencies (e.g. running away), the physiological changes (e.g. changes in blood pressure or size of pupil) and the motor expression (e.g. body language) [ 2 , 3 ].

How do emotions arise?

To give a brief interpretation, emotions arise from the body’s responses to external or internal stimuli. The response is dependent on your life experience, e.g. cultural factors, upbringing, education and so on [ 4 , 5 ]. Feelings are a part or an expression of/from these stimuli. A feeling can trigger an emotion or be the response to one. This means that the terms “emotion” and “feelings” are used to illustrate separate actions. Emotions and feelings are often used interchangeably in everyday language.

• Moral emotions

Moral emotions, instincts, and intuitions form the moral brain, which allows people to make ethical decisions, according to Haidt [ 6 ]. These emotions are the catalyst for promoting positive actions and avoiding negative ones [ 7 , 8 ]. People carry out actions and behaviours that are built on the information they obtain from previous experiences, both positive and negative. Moral emotions are the response to situations, sometimes of well-being, and sometimes of anguish or suffering of people [ 8 ]. The author classifies moral emotions into four families: condemning emotions, self-conscious emotions, praising emotions, and suffering emotions [ 9 ].

The difference between moral emotions and basic emotions is that the basic emotions come from ideas, the imagination or the perception of immediate self-realisation such as sadness, happiness, anger, disgust or joy [ 10 ]. The moral emotions are linked to the interests and/or the well-being of all people, as well as individuals. Furthermore, the moral emotions are evoked in circumstances that extend beyond the immediate sphere of self, such as empathy and compassion and, finally, the emotions relating to praising others, such as gratitude.

Finally, the main contribution to the caring ethic practices [ 11 , 12 , 13 , 14 ] is that it enriches our understanding of moral reasoning and decision-making. However, caring ethic practices include topics that have been ignored in rational ethical theories, such as the moral emotions.

Moral emotions in nursing care

Nursing care is an interpersonal experience and those providing care witness emotional signals that can be described as physical, psychological or existential [ 15 ]. These signals are considered to be a moral experience to perform moral work [ 16 ]. However, the motivation to act for another individual may involve an element of personal gain and it is plausible that nurses find caring for others emotionally rewarding. A study of 56 nurses found that nurses had more empathy than other health-care professionals. The author suggested that moral emotions and empathy may be a natural part of the profession, important for nursing roles and the caring process [ 17 ]. In nurses’ experiences of care, they also found experiences of emotional guilt, anger and frustration in relation to moral conflicts. Many of these situations were patient related and associated with acts of physical care that cross physical, social and personal boundaries [ 18 ].

Visible emotions in care situations

The interaction between the nursing professionals and other participants in the process of care is understood as an exchange of emotions, actions and experiences. In acute situations, it is necessary to focus and act quickly to continue the caring process. The arousal of feelings is secondary to the situation. It is impossible to avoid feelings, because feelings are a mental experience of body states, which arise as the brain interprets emotions.

Regardless of why emotions occur, whether or not they are appropriate or respond to certain cognitive patterns, our goal is to approach the emotions of professionals in acute care practice, emotions that arise from the interaction between the nursing professionals and other participants in the process of care. Our theory is that, if nurses are aware of their emotions, this will help them to cope in different situations. If a nurse learns to act intelligently as a result of emotions, this will improve nursing practice [ 19 ].

The overall aim of this study is to make nurses aware of moral emotions that could arise during their everyday work while taking care of patients and relatives in emergency situations.

To analyse how emergency nurses describe the moral emotions arising from emergency care situations.

Organisation

The study took place in Catalonia, Spain, at a university hospital and on the advanced life support (ALS) ambulance in the same town that has 131,255 inhabitants. In the present study, the aim was to select a group of nurses with experience in ALS ambulance care and emergency department (ED) care.

The sample of participants in the study corresponds to that presented in the first part of the study where the category ethical issues was analysed [ 20 ].

Sixteen nurses aged 27–47 years agreed to participate in the study. The nurses worked at the ED, at the ALS or both units. The mean time worked was 16.86 years.

The description of the socio-demographic characteristics as well as years of experience and type of participation in the study are reflected in Table  1 . All the nurses participating in the study were invited to participate in interviews and in the FG; 14 nurses took part in the interviews and 12 in the FG.

Data collection: interview

Data were gathered using interviews. The role as interviewer was that of an encouraging, non-normative neutral facilitator so that the participants could explain themselves as fully as possible [ 21 ]. Each interview took around 90 min, was recorded on an audio file and transcribed verbatim. Transcriptions have been made after each interview to provide a clear recollection of the interview; to increase the reliability, parts of the interviews have been listened to many times. To avoid interference during data collection, this was done outside the care units.

A semi-structured interview guide was created by the authors (Table  2 ) to facilitate these interviews with specifics topics on the relevant experiences of the participants. In order to stimulate reflections on the research phenomenon, follow-up questions were posed such as: Could you describe the situation? Do you remember the situation in a positive or negative way? How is the atmosphere in the service? Do you have any strategies for managing your feelings?

Data collection: focus group (FG)

The FG Each took around 120 min, was recorded on an audio file and transcribed verbatim. For the development, a FG guide was created (Table  3 ) according to help the expert in group dynamics, with some open questions from different themes arising during the interviews. In order to stimulate reflections on the research phenomenon, follow-up questions were posed such as: How is the care organised at the emergency/ED service? What kind of feelings and emotions do you have in emergency situations? How do the professionals react when faced by situations involving suffering and pain?

The FG technique allowed us to deepen in aspects related to their emotions and feelings in very diverse situations and that could be contrasted among the participants. The members of the focus group share experiences with one another, they are able to highlight individual viewpoints, empower the participants and validate their experiences and be regarded as an expert [ 22 , 23 ].

Data analysis

A qualitative approach was chosen and the collected data were analysed deductively, according to content analysis [ 24 ]. The primary aim of this is to describe the phenomenon in a conceptual form from different levels of content: themes and main ideas of the text as primary content and context information as latent content. In the process of analysis, three basic forms are used: summarisation, explication and structuring.

We carried out the analysis of the material from focus groups and interviews in several steps. After the verbatim transcription of the interviews, all personal identifiers were removed or replaced and a letter and a number were attributed to each participant. Deductive category application works with previously formulated, theoretically derived aspects of analysis, connecting them with the text.

The analysis explored the data to identify patterns in the way nursing expresses the emotions based on the classification by Haidt [ 9 ] to report the experiences and the reality of the participants based on a data-driven and systematic procedure which permits searching across data sets to identify repeated patterns of meaning [ 25 ].

Within this framework, systematic stages were followed and simultaneous analysis was undertaken. (a) The transcriptions were read and the data were re-read several times to obtain a sense of the overall data; (b) the text was divided into meaning units; (c) in the abstraction process, the meaning units were coded and the codes were compared, contrasted and sorted into preliminary subcategories; (d) by going back and forth among the preliminary subcategories, the codes and the text subcategories were identified; (e) the final step in the analysis was to use the categories according with Haidt’s moral emotions families which describes the entire results and connects all the subcategories. The analysis was carried out by the main author (M.J.) and the analysis was evaluated by means of discussions between all the authors during the analysis process and by emphasizing the emotions underlying the care experiences.

Ethical considerations

Clinic and ambulance managers were informed about the study, which they subsequently approved. This study was explained to the nurses in a group and they were told that (a) participation was voluntary and (b) they could leave the study at any time. Each individual gave her written informed consent to participate in the study.

The nurses participated on a voluntary basis and were reassured of data confidentiality. All the participants were verbal informed of the voluntary nature of the research and were told that their participation (or non-participation) would not affect their health services and after they provided written consent format to participate prior to data collection.

To maximise confidentiality, no names or other identifiers were recorded in the audio file or on the interview transcripts. The interviewers introduced the study in person and asked the participants whether they had any questions. The importance of maintaining the confidentiality of other participants, by not sharing their views outside the focus group setting, was stressed at the start of the interview.

Data from the transcripts of interviews and focus groups were collected according to the Law 15/1999 on the Protection of Personal Data. The research project was piloted and approved by the clinical committee at the reference hospital, according to Spanish law for non-biomedical studies.

We present one main category, “emotions and feelings in caring” relate with moral emotions. This category was strongly linked to the caring process. The subcategories were condemning emotions, self-conscious emotions, praising emotions and suffering emotions. Figure  1 shows the category with the different subcategories [ 20 ].

Condemning emotions

These emotions are related to the negative feelings nurses experience when they have to take part in ethical situations related to the care given by other professionals. In this subcategory, we could include feelings such as disgust, anger or contempt, which sometimes arise in extreme situations when the treatment that is given is not appropriate or when practices could be described as inhuman or violent, e.g. compulsory. The nurses expressed these feelings from emotions when their viewpoint was not taken into account in the decision-making process. They were not allowed to be involved in the planning of good care and felt that the medical treatment displaces nursing care and does not include it as a part of the patient’s treatment process. When nurses talk about the treatment of pain, they see it as an ethical matter and, when it is not addressed adequately, this generates a feeling of anger in them.

“ … that’s why I get annoyed. Because, despite having many tools, we still have to keep asking whether or not to give the patient a painkiller. This triggers one’s temper, to say: ‘come on, this person is suffering’, e.g. vascular patients who have had pain for many hours, it’s very easy to give them something.” GF:R4 [ 6 ]

The nurses also felt anger in situations when the assessment did not involve both patient and family and when actions that were unnecessary for the patient were performed. The feeling was that some professionals only focus on an organ or a set of organs, while some view the person as a whole, taking account of other aspects that are an important part of life.

"( … ) in my experience, the patient's life is prolonged as much as the doctor wants and maybe the patient has written not to resuscitate him or her in the event of cardiac arrest. I don't understand it, you are telling me there's nothing we can do and we are filling them up with tubes, serums, catheters, drugs... if there is no chance of waking up, why are you prolonging unnecessary agony? The patient can't feel a thing, but what about the family members?

“You should see how they suffer, how they cry... it tears your heart out. Even if you ask the doctor ‘what are you doing?’, if he thinks that they have to keep on, they keep on... Finally, the patient will die, but adorned like a Christmas tree, not as a human being. Yesterday, a woman died on my watch about whom, for more than a week, we had only heard “there's nothing we can do”, but she wasn't short of anything, noradrenaline, tubes, catheters, serums... There comes a time when you get tired of speaking and not being listened to.” GF: R10 [ 19 ]

Self-conscious emotions

Self-conscious emotions provoke negative feelings like shame, guilt or embarrassment. Nurses report that, when they had experienced a situation in which they believed they could have helped the patient differently, but the conditions at the time did not permit it, they felt guilty about having taken part in the process. Nurses feel vulnerable in these situations where they cannot act.

The emergency nurses highlighted the fact that the lack of teamwork between professionals harms the patients and provokes these emotions. The lack of teamwork also impairs the individual effort and the relationship between all the participants in the health-care team.

“(...) the professional relationships must be based on consensus within the team, because, if there is no dialogue, nothing works in the optimal way. At the hospital, the team doesn't talk, there is no dialogue, they don't work well together... this often results in many ‘loose ends’ and a lack of understanding about what happened... each member plays his part and it goes as it goes (...) this makes me feel ashamed about not being able to solve it (...).” ENF2 [ 2 ]

Nurses feel shame and guilt because they see clearly that there is no teamwork and this affects the caring process.

Praising emotions

Within this subcategory, we include the feelings that could be defined as satisfactory and positive; they arise when nurses feel that care has met its objectives and that there has been an appropriate response to needs. Nurses highlight the fact that these positive feelings gratify and motivate them to continue advancing and developing a more complete and satisfying nursing practice for both patients and professionals.

“(...) helping people makes me feel fulfilled, you are next to them in very serious and critical situations and we are behind the care given at these difficult moments. We help them with their problems; help them to keep on living. Sometimes we find that we are powerless because we can’t do anything to help them... that’s the two sides of the same coin (...).” Enf2 [ 7 ]

Another participant highlights the need to do the right things to experience this kind of feeling, because it produces a significant degree of personal satisfaction as a professional.

“(...) sometimes the situations fluctuate tremendously, we can go from one extreme to the other: from maximum satisfaction to the utmost helplessness. I am determined never to fail, I must be one hundred per cent. Feelings like this help me to act. It requires an extra effort because time is precious and perhaps we have to resolve situations that may endanger a patient’s life. At the same time, they help me to develop as a human being ( … ).” Enf8 [ 4 , 5 ]

When nurses participate in this decision-making process, they feel good in spite of the difficulties that may arise in the situations they must face.

“(...) in emergencies, things happen quickly and we often don’t have time to stop and think, I feel that I am part of the situation I am in ( … ).” Enf8 [ 8 ]

Suffering emotions

The nurses felt that care, as seen from a nursing perspective, has a sensitive dimension that goes beyond the patient’s own healing and, when this is in conflict, it dehumanises the assistance. Nurses believe that the caring perspective must consider a special moral sensitivity in order to respond to the needs of the patient.

The informants state that distress coming from a morally negative emotion is the main source of moral distress. Moral distress is made up of emotions that appear when, for various reasons, it is impossible to follow the right course.

Nurses suggest that there are external constraints that cause these situations, such as the institutional structure and its bureaucratisation, as well as the strict hierarchy that exists among professionals in hospital. This situation has its origins in a power structure, more or less open, and, in other cases, invisible influences in the nursing/caring process.

According to one of the nurses:

“(...) no, you are not taken into account for anything. If you were, sometimes things would have gone differently, at least from my own experience. You can argue, discuss, share opinions, it’s all useless. According to them, they are the captain and a sailor has to obey. Sometimes you are certain that the patient is going to die, but we still purify the blood and give antibiotics. We treat them with the most advanced and expensive therapeutic facilities Do you have any idea how much a haemofilter costs? Do you know how much unnecessary spending is generated? Do you know how much suffering we cause people? It is hard to live with this, I get angry, we talk about it with our colleagues... you can't do anything and feel helpless. However, when I see these atrocities, I tell them: ‘don't ever do that to me’. The most distressing thing is when the patient's family comes in and you see that agony. It breaks my heart and I realise that I am part of this...” Enf10 [ 9 ]

The informants sometimes felt that they were used to reaffirm the treatment and they did not have enough power to be the patient’s advocate. The following informant tells us about her experiences.

“(...) no, they don't ask you. They very seldom do, but, if they do, it’s because they are searching for reaffirmation of their opinion and to be told that they are doing the right thing.” Enf3 [ 8 ]

“(...) No, no, we don’t take an active part. Everything is under their control, everything is medicalised. Until the day arrives when nurses are on the same level as doctors and their work is valued by the medics, it will be very difficult for nurses to take part in the decision-making process when confronted by ethical issues (...).” Enf 4 [ 9 ]

The nurses say that they want to participate in the processes, bringing their experience and knowledge, but they feel that their opinions not are taken into account.

“(...) Nowadays, nurses are in the clinical sessions, but their opinion is not taken into account; this should change gradually, the nurse knows the patients and defends them from aggressions that might occur even from health professionals. They do not usually take account of the information we provide, Physicians make decisions one hundred per cent of the time based on subjective criteria, which appear to be the only valid ones (...).” Enf 6 [ 8 ]

The overall impression from the findings from this extensive material was that nurses were preoccupied with existential thoughts about positive and negative moral emotions derived from caring relationships, such as emotions.

Moral emotions are linked to welfare, to do good and avoid doing bad. The present results found that the nurses who participated in the study indicated aspects that confirmed the existence of moral emotions that influence the caring process, sometimes positively and sometimes negatively.

Nurses are likely to feel condemning emotions like anger when assessing a situation relating to the patient and his/her family which goes against their view of the way things should be done and when they believe that action that is unnecessary for the patient could be avoided.

To do good from a nursing perspective is to take account of dimensions including the relationship between the patient and family. This perspective often differs from other sciences which focus on the biomedical perspective [ 11 ].

From the perspective of condemning emotions, anger is linked to the interests of others rather than to themselves. From this perspective, anger is a motivational force that energises the individual to defend situations in order to provide better care and avoid damage to the patient [ 10 ].

We found that this type of negative feeling constantly recurred in the emergency practices and was a topic of consensus among the interviewed nurses. Nurses need to develop their role in the team and other professionals need to include them in the ethical decisions. Other studies have shown the need for a nursing perspective in similar situations [ 26 , 27 ].

Emotional responses from nurses in these situations vary a great deal. The informants state that a morally negative emotion is the main source of moral distress. Moral distress appears when, for various reasons, it is impossible to follow best practice and is independent of context-given specific preconditions: when nurses are morally sensitive to the patients’ vulnerability, when nurses experience external factors preventing them from doing what is best for the patient and when nurses feel that they have no control over the specific situation [ 28 ].

This gives the professionals a sense of helplessness, frustration, anger, resignation and guilt. What is worse, it can provoke states of depression associated with the loss of professional integrity, feelings relate with self-consciousness moral feelings.

Nurses has suffering feelings from the most common sources are excessively aggressive treatments, the misuse of resources, a lack of communication between professionals and patients, treatment goals that are poorly defined and poorly understood by all the members of the care team, a lack of respect for the will of the patient and the loss of continuity of care due to a lack of collaboration and consensus; both excessive interventions and the therapeutic neglect of patients could result from the latter actions [ 20 ].

The nurses suggested that there are external constraints that cause these situations, such as the institutional structure and its bureaucratisation, as well as the strict hierarchy that exists among professionals in hospitals. Hierarchy often results in the abuse of power and this then results in internal conflicts, more or less open, and, in other cases, invisible [ 29 ].

The nurses feel that they are the patients’ advocates and they cannot simply be governed by feelings of resignation and pessimism. They need to do something more. Nurses need support, strategies and solutions from the organisation to demonstrate their role as the patients’ advocates [ 30 ]. The collaboration between nurses and doctors could lessen feelings of moral distress if they felt included in the decision-making process [ 31 ]. They need to participate in these interdisciplinary teams. However, the interviewed nurses felt that clinical practice was far removed from achieving an adequate minimum of inter-relationships and, according to them, this only exists in the theoretical discourse [ 32 ].

Positive emotions are also present in clinical practice, even if, in many cases, emergency situations can be dramatic. These situations can, for example, give the professionals emotions such as gratitude and satisfaction. These emotions arise when nurses see that care meets the predicted goals and they have been able to respond to the needs. Positive emotions are beneficial for the professional experience [ 33 ].

The nurses point out that these positive feelings gratify and motivate them to continue advancing and developing a successful practice for both patients and professionals. Positive feelings prevent emotional exhaustion and help to prevent bad confidence [ 34 ].

The expression of care arises from a unique situation involving the nurse and the patient where both have expectations of a result. It is a unique and specific situation that cannot be repeated. To understand these relationships, it is necessary to contextualise instead of generalising when it comes to worrying about the principles that guide the action. Caring professionals are concerned about the person they care for. This creates feelings that give meaning to the interviewed professionals in their daily practice. If the professionals are aware of positive and negative moral emotions, this will help them to reach levels of personal satisfaction, self-fulfilment and moral reinforcement [ 35 ].

From this respect, the moral duty of health professionals not only lies in the effective exercise of their profession, from a technical point of view, it is also ethical and aesthetic experience implies the creation and/or appreciation of caring situations.

The praising emotions are living like a positive feeling is reinforced when they are praised for their work and this leads to emotional well-being which improves their quality of life from both a personal and a professional point of view [ 36 ].

Limitations

Qualitative studies do not attempt to generalize results and therefore have some limitations. The present study was limited to a small sample size, which is characteristic of qualitative methods. The purpose of using the content analysis process was to interpret experiences based on an in-depth analysis of single cases rather than to generalise across a large number of cases.

When performing a content analysis interpretation, we do not expect to find a single universal truth, but instead we search for possible meanings in a continuous process. There is always more than one way to analyse and interpret data and the results of this study represent one of several possibilities.

The present findings illustrate the experiences of nurses. This research was conducted only with female nurses and could be biased in its results, but this could be the basis for future interventional studies and further dialogue in the ethical setting in clinical practice including gender perspective.

The “moral emotions” contain feelings, some negatives and other positives, like shame, guilt, sympathy, empathy, contempt, anger, disgust, moral distress, joy and happiness Moral emotions are connected to the caring process in emergency and critical situations and so, from a nursing perspective, the study of moral emotions brings into play a larger array of feelings that will help us to understand the dynamics of the relationships involving the patients, the families, other professionals or institutions. It is therefore necessary, in a critical and rational manner, to develop a multidimensional analysis of care including both anthropological and ethical aspects and as much in its technical aspects as in its anthropological and ethical aspects. It is crucial not to ignore these emotions, because they are present in all caring actions.

The engagement between nursing practice and patient in vulnerable situations such as emergencies has a strong emotional element. A patient may elicit compassion, concern, pity or indeed anger or frustration. The nurses felt that they were unable to develop caring science because technological tasks play a greater part than in the caring process in place of the human dimension of care.

The nurses felt negative moral emotions like anger and frustration when restrictions affected the human dimension of quality of care. This was a problem, because they were unable to see any possible way of developing as professionals, to create a new kind of human care where the technology is involved but is not the main objective.

When nurses feel that they are working from a compassionate care perspective, this generates positive feelings like sympathy or happiness both for the staff and for the patients and their families. These aspects are very important and are the main aim of the nurses’ work. A nurse’s knowledge and skill are important forces that can contribute to the power to influence patient care in an ethical manner. This power comes from the nurse’s knowledge and expert skill.

To influence patient care, a nurse needs to be aware and also needs to understand the influence of moral emotions. This knowledge arms the nurse with power in the decision-making process relating to patient care. A nurse who understands his/her moral emotions can use this understanding to influence the health-care team and can apply it to the caring process by influencing both actions and behaviour.

Availability of data and materials

The raw data supporting the findings presented in this study will be available from the corresponding author upon request.

Abbreviations

Advanced life support

Emergency department

Focus group

Emergency medical system

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Acknowledgments

The authors would like to thank to all participants who were interviewed and the Hospital for giving the opportunities to conduct this study and we are grateful for this permission.

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María F. Jiménez-Herrera, Sagrario Acebedo-Urdiales, Leticia Bazo-Hernández & Isabel Font-Jiménez

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Prehospital and Emergency Care, Faculty of Caring Science, Work life and Social Welfare,The Center of Prehospital Research, University of Borås, Borås, Sweden

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MJ collected data, MJ, MLL, SA, LB, IF and CA performed the analyses and literature search, and drafted the text as thesis. MJ conceptualized and designed the stud. CA coordinated, supervised and analyzed the data, and assisted in final write-up of the manuscript. MJ, MLL, SA, LB, IF and CA participated in conceptualizing and interpretation, and provided critical review of drafts. Then all read, and approved the final manuscript.

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Jiménez-Herrera, M.F., Llauradó-Serra, M., Acebedo-Urdiales, S. et al. Emotions and feelings in critical and emergency caring situations: a qualitative study. BMC Nurs 19 , 60 (2020). https://doi.org/10.1186/s12912-020-00438-6

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Research Article

Mental model for information processing and decision-making in emergency care

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

* E-mail: [email protected] , [email protected]

Affiliation Nursing Department, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia

• Modi Al-Moteri

• Published: June 9, 2022
• https://doi.org/10.1371/journal.pone.0269624
• Reader Comments

Uncertainty and time pressure in emergency departments add a challenge to the rational decision-making process, specifically when encountering a critical patient who requires a prompt response. However, there has been little attempt to develop a mental structure model to understand the thought processes and identify cognitive weaknesses points in nurses’ decision-making. A better understanding can inform changes in both practice learning strategies and decision-making in emergency department. This study aims to better understand how newly employed nurses process information and initiate actions in emergency situations characterized by time constraints and uncertainty.

Participants worked under time pressure and uncertainty to solve a simulated shock case by establishing an assumption of what type of shock the simulated patient might have and its cause. An 8-minute window was available to initiate action. Following the simulation, a retrospective think-aloud interview was conducted.

Participants’ ability to identify the category of shock was better than their ability to identify the underlaying cause of the shock. This influenced their ability to intervene correctly. Participants’ thinking process in an emergency situation can be organized using ABCDE acronym as follows: (1) a wareness of the situation, followed by, an instant (2) generation of b eliefs (presumption), (3) c ontrolling the c onsequence (first-line management action), (4) involvement in d eliberate thinking and, finally (5) e x e cution, actions (second-line management action). The cognitive weakness was mainly noticed during the first-line management action when participants were involved in immediate lifesaving activities.

Classification of the steps involved in decision-making when encountering emergency situations may provide insight into the strengths and weaknesses of the thought process at different stages. Further studies are required.

Citation: Al-Moteri M (2022) Mental model for information processing and decision-making in emergency care. PLoS ONE 17(6): e0269624. https://doi.org/10.1371/journal.pone.0269624

Editor: Darrell A. Worthy, Texas A&M University, UNITED STATES

Received: January 4, 2022; Accepted: May 24, 2022; Published: June 9, 2022

Copyright: © 2022 Modi Al-Moteri. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the article and its Supporting Information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Uncertainty and time pressure are common and unavoidable in emergency nurses’ practice [ 1 , 2 ]. These conditions add a challenge to rational thought process, specifically when encountering a critical patient who requires a prompt response [ 1 ]. Uncertainty is a "mental state" experienced by nurses when trying to decide between two or more actions [ 2 ]. Meanwhile, time constraint is a kind of psychological pressure that add stress on nurses when they have less time available than is necessary to complete a task or obtain an intended care result [ 3 ].

Time pressure and uncertainty are widely recognised experienced phenomena that may have substantial negative effect on patient safety [ 3 , 4 ]. Failure to identify patients who have a serious and potentially life - threatening problem is well documented in literature [ 5 ]. The problem may be explained in part by poor information processing, causing a delay in responding. Information processing refers to the ability to perceive, interpret and connect “relevant information whilst filtering out unnecessary information” to generate a decision and initiate actions [ 6 ].

Information-processing in clinical decision-making is based mainly on two systems of thinking processes, called System 1 and System 2 thinking approaches [ 7 ]. System 1 thinking approach is often described as “pattern recognition”, in which a schema in long- term memory is activated by certain cues to form an assumption [ 7 ]. It is generated almost instantly without much thinking effort by matching patterns with existing knowledge obtained form similar past situations; this is also known as the “gut feeling”. However, the System 1 Thinking approach does not necessarily produce a correct assumption [ 8 ]. Meanwhile, System 2 thinking approach involves “deliberate thinking” and is more “analytical,” and rational [ 7 ]. System 2 thinking approach is generated by collecting, searching for additional information. The data are then processed carefully, and consciously [ 7 ]. It is, indeed, slower than System 1 Thinking approach and a cognitively demanding process but is more likely to generate better decisions [ 9 ]. However, System 2 to System 1 thinking approaches may be used interchangeably to solve problems [ 7 , 9 ].

Nurses’ practice in emergency settings is characterized by being action-driven rather than analytic-driven [ 9 ]. This is because nurses in other clinical settings generally use an analytical method (System 2 Thinking approach) which is an information-seeking method and involves history-taking, physical assessment, and investigations. This method of thinking helps nurses to prove their thinking outcomes and reach a conclusion about the specific situation [ 10 ], particularly when the nurses fail to match the patient’s clinical cues with a specific disease classification script [ 11 ]. Meanwhile, nurses in emergency settings are required to act immediately in the absence of or having limited information that can be obtained from patient history, physical examination and medical investigations [ 9 ].

In spite of the abundance of literature addressing the characteristics of emergency settings [ 4 , 8 , 9 , 10 ], there has not been a mental structure model proposed to understand the thought processes of clinicians and to identify particular cognitive weaknesses [ 6 ]. A better understanding may inform changes in both practice and decision-making in the emergency department setting.

This study aims to better understand how new graduate nurses process information and initiate actions in emergency situations characterized by time constraints and uncertainty.

Materials and methods

This is a descriptive exploratory qualitative study design in which retrospective think-aloud interviews were conducted [ 12 ] that investigated the underlying thought processes and actions of newly graduated nurses while identifying a type of shock and initiating appropriate actions.

Simulation was conducted at the regional hospital in a Simulation Unit (SU). The unit is used as a resource for in-service training of medical clinicians, nurses and other healthcare professionals to improve knowledge, professional and clinical skills for fulfilling various responsibilities. SU provides low and high-fidelity manikins and standardized patients.

Participants

The simulation session was offered to all newly graduated nurses (n = 25) recently employed at one of the regional hospitals. The simulation session was part of the training and orientation program introduced by the hospital. The program is introduced to the newly employed healthcare providers and included some theoretical lectures, simulation sessions and field training. It is aimed to prepare newly employed healthcare providers for entry into clinical practice by introducing them to the policies and procedures at the workplace (e.g., "vital signs monitoring, waste management, tube insertions, patient assessment, injection administration, intravenous infusion"), new technologies and etc. All the 25 participants were invited to voluntarily join the study. Of those, 12 male nurses agreed to participate.

The SU consisted of three forms of simulation: high fidelity simulators (e.g., SimMan), low fidelity of simulators (e.g. dolls) and a standardized patient. In the current study, the standardized patient was a male trained to portray patient scenarios for the purposes of teaching, training, and evaluation of trainees’ performance. The standardized patient was a certified simulation technician who is in his late 40s and interested in acting and has excellent communication skills. He was selected based on the case requirements which include gender, age, physical appearance, attributes and acting ability and experience. The standardized patient received a two-hour training session preceding the simulation session to ensure that information is retained. He was instructed to depict the case consistently for every trainee. The simulated session was designed to be as realistic as possible to enhance the training experience. The simulated session followed three traditional phases of healthcare simulation: "pre-briefing, simulation, and debriefing".

Phase-1: Pre-briefing.

Prior to running the ’simulated session’, a pre-briefing phase was conducted. In this phase participants attended a session in which the objectives of the study were explained. Participants were instructed how to complete the simulation and advised that they would be assigned to a 73-year-old diabetic male who had experienced vomiting for four days. Each participant had eight minutes to rapidly assess the patient, record key clinical findings in a chart, and attempt at least one nursing action before moving to the next briefing phase.

Phase-2: Simulated session.

The ’simulated session’ phase was then conducted. The clinical instructors of the Critical Care Unit designed a scenario of a shock syndrome case that represents a typical clinical emergency situation frequently encountered. Two experts in the field of adult intensive care—intensive care consultants—were invited to review the goals and the content of the designed scenario. Slight modifications were suggested on some of the supporting data associated with the scenario (diagnostic studies results). The experts, then agreed that the case designed was reasonable and reflect the realities of the clinical practice.

There are several categories of shock syndrome—(1) hypovolemic, (2) cardiogenic, and, (3) septic and each results from different cause and has a different medical management. Shock syndrome is defined as the inadequate means of arterial blood pressure to meet the needs of the tissues and body organs [ 13 ]. Although the underlying causes of these categories of shock syndrome are different, they have some similarities and differences in clinical presentations. This may create a degree of uncertainty for a nursing clinician and might be mistakenly interpreted [ 14 ].

Since this simulated scenario is introduced by a regional hospital for training and orientation purposes, all newly employed nurses (n = 25) are mandated to take part in this program, however, only those (n = 12) who agreed to take part in the current study, were videorecorded ( Fig 1 ).

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https://doi.org/10.1371/journal.pone.0269624.g001

As the participant entered the room, there is, adult male who is wearing a hospital gown, sitting at a 45-degree angle and showing facial expression of pain. He is making moaning sounds expressing physical suffering, cough, and takes labored breaths. A pulse oximeter probe is placed on a finger, and a nasal cannula is in place; oxygen flow at 2 L/min. The vital signs monitor is turned on. Peripheral IV access is established. A glucose measurement device is placed near the patient. Initial clinical information were:

• Temp: 36.9°C
• Pulse: 134 /minute
• Respirations: 32/minute
• Oxygen saturation: 100%
• Blood pressure: 88/45 mm Hg
• Weight: 70 kg
• Mental status: lethargic; oriented to time, place, and person; cognition intact; answers questions appropriately

At the bedside, a registered nurse taking the role of an emergency department (ED) nurse, hands an ED Note to the participant. During the scenario, the ED nurse provides further scripted information that cannot be portrayed by the simulated patient while staying in role. The ED nurse provides participant the diagnostic studies, if requested by participants.

At the time of the simulation, each participant had eight (8) minutes to assess the standardized patient, take and record key clinical findings (e.g., vital signs, physical appearance, laboratory results) in a chart, and attempt at least one intervention. The time given to participants together with the accessed clinical information was just enough to perform a focused assessment, identify the type of shock the etiology and decide upon action. Since this simulation case could be any of the three shock categories: (1) hypovolemic, (2) cardiogenic, and (3) septic, the equipment necessary to manage each shock syndrome was available and visible on a cart.

The 25 newly employed nurses were divided into two groups: those who agreed to participate (n = 12) and those who had no interest to participate (n = 13). The simulation activity was standardized at 12–15 minutes long and was run 12 to 13 times a day (from 9:00am to 01:00pm) for two consequent days. To prevent participants’ revealing knowledge of the task from their colleagues and peers, the 12 participants who agreed to participate in the study were assigned to be the first to commence the simulated activity.

Immediately after assessing the patient, each participant completed the performance sheet for the simulated patient. Participants noted key observation findings, clicked or circled the suspected shock category and the etiology and the chosen medical and nursing management. For example, the participant could circle “hypovolemic”, “cardiogenic”, or “septic” for the shock category.

Phase-3: Interview.

Once participants finished their simulated scenario task, they were invited to review the recorded video of their performance and to reflect on their actions. From the 12 participants who showed interest in participating in the study, 10 were interviewed and two refused ( Fig 1 ). A 15–20 min interview was conducted. The participant was again shown a recorded video of his performance and was asked to explain his actions. This retrospective think-aloud interview was conducted by the researcher to promote reflection of participants on their performance with respect to the scenario and to identify the underlying cognitive process they used ( S1 Appendix ). Questions such as “Help me understand why you do that and this…” and “tell me more about…” was used to reveal the participant’s own thought processes used to interpret the clinical situation. Immediately following the retrospective think-aloud interviews, participants were debriefed to allow them to reflect on the experience, analyse and revealed their emotional states.

Phase-4: Debriefing.

Once the interviews were completed, participants were gathered for group debriefing. A senior clinical instructor facilitated the debriefing. Participants were encouraged to describe their feelings about the experience. They were also encouraged to state "What went well and what did not go well and why?". They were also asked "What was the main take-home message?".

Ethical approval

Ethical approval was granted from the Ministry of Health Ethical Committee. Written informed consent was obtained from the willing participants. Participants were informed that their participation was entirely voluntary and that their contribution would enhance the development of clinical practice and training. An Explanatory Statement relating to the study design and purpose were given to the participants. Participants were informed that confidentiality and anonymity would always be maintained and were given the freedom to withdraw from the study at any point in time. Any concerns were addressed. Participants were informed that study results would have no bearing on the formal evaluation of their training program. To maintain privacy, interviews were conducted with the participation of only the interviewer and the interviewee. The study was conducted with the hospital clinical instructors’ involvement following a unit coordinator agreement.

Data analysis

Ten interviews were transcribed and analysed. For the researcher to understand the cognitive processes underlying the information seeking behaviour in the context of shock syndrome, a hybrid thematic analysis approach was conducted [ 15 ]. The approach combined two philosophical reasoning techniques: deductive (a top-down reasoning), and inductive (a bottom-up reasoning) [ 15 ]. The inductive analysis phase mainly allows themes to directly develop from the qualitative data. In the current study and during the inductive phase, the researcher read and reread the transcripts to generate a general understanding. Initially, in the inductive phase a total of 74 codes were identified. Saturation was reached after approximately seven interviews. The identified codes were then reviewed, reorganized and similar codes were grouped [ 16 ]. A second round of a deductive analysis was initiated to enable an in-depth exploration of data in line with the existing literature. In the deductive analysis phase, the emerged codes were aligned with the findings of the previous studies presented in Al Moteri et al. [ 4 ], Al Moteri et al. 2020 [ 6 ], Al-Azri [ 17 ], Al Moteri [ 18 ]. In particular, the theoretical frameworks constructed by Al-Azri [ 17 ], Al Moteri [ 18 ] have guided the presentation of themes and codes and their interrelationships ( Table 1 ). Themes were then organized using ABCDE acronym for easy use.

https://doi.org/10.1371/journal.pone.0269624.t001

A summary of the findings supplemented with the appropriate descriptive repeated quotes was prepared ( S2 Appendix ). At this point, five themes were generated and supplemented with the appropriate descriptive repeated quotes. The demographic and performance data were presented in the form of percentage.

Quality of the data

Several strategies were used to maintain “credibility”, “transferability”, “dependability”, and “conformability” of the data [ 19 ]. Transcripts were examined and checked by an external reviewer to ensure “credibility”. For the sake of maintaining “transferability”, participants were invited to judge the end results of data analysis. Ensuring “dependability” was made by careful development and preparation of all the steps of the study, including data collection and analysis. The investigator always kept in mind the aim of the analysis—to investigate the underlying cognitive process of cue recognition. Finally, “conformability” was maintained through using virtual presentation of the data.

This section may be divided by subheadings. It should provide a concise and precise description of the experimental results, their interpretation, as well as the experimental conclusions that can be drawn.

Participants’ demographic and performance data

A total of 12 participants agreed to participate and completed the performance sheets. Their ages ranged from 23 to 25 years old, with the mean age being 23.3 years old and the standard deviation being 0.64. They were all male graduated from the same educational institution and their GPAs ranged from 2.6 to 3.4 out of 4, with the mean score of GPA being 2.85 points and the standard deviation being 0.27. Of those 12 participants, 10 completed the interview.

Reviewing the performance sheets of the 12 participants revealed that nine participants (75%) correctly identified the shock category and out of these 9 participants, five (56%) determined the correct etiology. Participants’ failure to identify the etiology has influenced their ability to intervene correctly. Indeed, actions varied considerably. Due to the participants’ characteristic similarity, no association between study subthemes and students’ characteristics was sought.

Data from the ten interviews contributed to describe several main mental activities reflecting new graduate nursing students’ actions triggered by uncertainty, namely, (1) a wareness of the situation, followed by, a prompt (2) generation of b eliefs (presumption), (3) c ontrolling the c onsequence (first-line management action), (4) involvement in in d eliberate thinking and, finally (5) e x e cution of actions (second-line management action). These themes represent the underlying cognitive processing of the information described by the interviewees.

Theme-1: Awareness, sensory processing.

When participants met the simulated patient, they instantaneously began to perceive the context. Their perception at this early stage was mainly based on highly visible and easily notable information presented by the patient or in the surrounding environment. In this step, the brain immediately began to process the sensory information obtained from multiple sensory modalities to form general understanding. Emergency nurse’s expectations, skills and knowledge all may contribute to the initial perception of the emergency situation. The instant sensory processing of the contextual information is very important in guiding decision-making when encountering an emergency situation. For instance, some of the participants verbalized how quickly, in a matter of seconds they noticed the appearance and the behavior of the patient:

“…when I entered the room , I immediately noticed how he is in the bed holding his stomach … you see him… he (the patient) is laying on his right side …. curling and holding his stomach…" ".. though I didn’t ask him anything yet in that moment but … he is (the patient) frowning and grimacing his face , give me a clue that he is in pain……” " … you can hear him moaning … … when I entered the room , I immediately heard the moaning and when I approached him , I found him on the bed and laying on his right side … "

The significance of this instant sensory processing is not reflected adequately in the emergency decision-making process [ 17 ]. Typically, decision making in emergency situations has focused on the outcomes rather than the process [ 17 ].

Theme-2: Belief (assumption), generating.

The sensory processing of the contextual information in the previous step is interpreted in a matter of seconds to generate a preliminary clinical assumption (impression). The assumption is formed unconsciously and on the basis of little evidence. It stimulates participants to go beyond the contextual perception of what is going on, as shown in the comment below:

" …. from his facial expression and body movement…it didn’t take me long to realize he is in pain …I can tell he is in great pain…" The way he was holding his abdomen, the grimace on his face , … you can see his facial muscles twitching… . I think he is in pain and his pain is getting worse

Theme-3: Consequences, controlling.

Participants in the current study attempted to look for leading but critical signs that could reveal immediate risks. The goal of this quick scan is to identify and manage any potential life-threatening conditions. For example, participants ensured optimal breathing and circulation, as shown in the comments below:

"…he is not choking but he breathes fast…I can tell he is having some serious problem …. a little bit increase of O2 (Oxygen) would do no harm but it may save his life.. you see me too busy giving him O2 mask…I’m thinking … he might need a defibrillator.. I should be ready too.." “…. he is vomiting , not to say that intake might be decreased… I should immediately put him on a fluid balance if I want to save his life…" “… so like you might go by the BP (blood pressure) , … If he is a bit dry, he’s blood pressure might be low…. so the quicker you get cannulas into him, the better end outcome is…" "… . you know if pain is intense , he may faint at any moment…. you can see me too busy keeping my eyes on him…"

It is typical in emergency situations to think about potential threats and intervene promptly. This is done through shortening the thinking process rather than a detailed evaluation. Mental shortcuts are considered useful and even necessary in emergency situations under time constraint and uncertainty. Mental shortcuts offer rapid assessment and permit immediate action to safe patient’s life. However, this fast thinking does not always lead to correct actions and outcomes. For example, the assumption of bleeding might be made based on signs such as low blood pressure and the high pulse rate, as follows:

“…from a lower blood pressure and a high pulse rate … I can tell there’s a bleed going on there……I should administer blood or call for help…” “.. his (the patient) blood pressure is dropping… he’s losing blood ; it is life threatening problem,.…I should get it up (blood pressure) with legs up”

Theme-4: Deliberate, thinking.

Once immediate risks and threats have been controlled and managed, participants may start to devise a workable clinical assessment through an analytical process. Participants in this stage tend to arrange, analyse and relate clinical information, form some queries that attempt to test the assumption by looking for information that confirm or, alternatively, reject it. See the comments below:

“…I checked ECG , I wanted to make sure that it wasn’t cardiac problem…” “BP (blood pressure) low,…. I thought well , I’d better check his temperature because if he got a rupture appendix a bit of a temperature that might be going up….but the temperature was normal” “I thought , well if the urine is dark that’s give me clue that he (patient) is dehydrated …. and obviously the BP (blood pressure) is low.…" “…I auscultate the chest….you know it is common to have lung disease when you are old .. but the lung was clear again and the CXR (chest x-ray) was also clear…"

Theme-5: Execution, actions.

Based on the outcomes of the deliberate thinking, an overall plan that includes actions to manage the patient problem is produced. This step does not oppose the action initiated earlier to safe the patient’s life ( C ), nevertheless it helps emergency nurse to have holistic view to manage the case. See the comments below:

“… so you go by dehydration … . you can see me giving him antiemetic and monitoring fluid balance…"

This study explored the thought processes of 10 newly graduated nurses while they managed patients with unknown shock syndromes using retrospective think-aloud interviews. To our knowledge no previous studies have explored the thought process of nurses under time pressure and uncertainty in relation to emergency clinical problem. This study gives new insights into how the inherent uncertainty in patients with unknown problems is managed by nurses in emergency care. For nurses, working in emergency settings in hospitals is always "stressful, time sensitive, life-critical, and information poor and loaded" [ 6 ]. Making an optimal decision under such conditions is difficult and sometimes challenging [ 5 ]. How health providers use their cognitive and attention resources in emergency situations is sometimes overlooked area of study [ 17 ]. This study dissects the mental activities of nurses in emergency care into five steps. These steps might be used to represent the thought process of nurses during emergency decision making when encountering a critical patient who requires prompt response.

A mental model ( Fig 2 ) was proposed as a summary of the research findings. It illustrates the process of decision-making when encountering an emergency situation with limited information. The proposed mental model steps were arranged in an alphabetical order from A to E for easy use and recall: ( A ) awareness of the situation by sensory processing of the contextual information present in the patient and environment. Evidences have suggested that being aware of the situation increases the likelihood of a “good” decision [ 20 ], specifically in urgent situations that demand rapid decision-making [ 21 ]. Awareness can be achieved through many sensory channels (visual, auditory and touch) [ 21 , 22 ]. In the current study participants visually observed the patients’ facial expression and the position of the patient on the bed and heard the voice the patient produced. Once awareness is maintained, an instant ( B ) belief (presumption) about the situation is generated through interpreting contextual issues. In emergency situations where uncertainty is high, healthcare providers may rely on highly visual and readily available information to make a decision [ 23 ]. In the current study, the nurses assume that the patient has pain from interpreting the patient’s facial expression and behavior. Such an assumption is a typical System 1 Thinking approach and is generated almost immediately upon encountering the patient [ 5 ]. This is followed by close observation and a search for critical signs that may indicate the presence of threats on the patient’s life in an attempt to ( C ) control the consequence by initiating immediate lifesaving actions. This is in line with what was reported in the literature [ 17 ]. Nevertheless, step (C) may not be correct under uncertainty and time pressure. Indeed, in the current study inappropriate actions to prevent further deterioration of the patient, were noticed. Although it was not the focus of the current study to investigate why it was more likely for participants to make errors in ( C ) step under time pressure, researchers reported that time pressure tends to increase the perception of the difficulty of the task [ 24 , 25 ]. The ( C ) step however, represents a connection point between System 1 Thinking approach—step ( B ), and System 2 Thinking approach in the next step ( D ) which involves a deliberate thinking. Step ( D ) involves analyzing and investigating clinical information for optimal decision-making. Finally, in ( E ) execution, actions are initiated to start intervention or to continue observing and monitoring the patient.

https://doi.org/10.1371/journal.pone.0269624.g002

The proposed conceptual mental model may contribute to the development of certain clinical reasoning skills useful to develop in emergency practice, particularly, those used in emergency settings. In addition, the practical classification of the thought processes of nurses during emergency decision-making provided additional insight into the cognitive weaknesses in the process in which lapses and errors may occur [ 6 ]. Hence, to devise practical training to strengthen the weak areas of thinking may be helpful. An inherent issue in emergency setting work is its chaotic nature [ 17 ]. The best approach to manage a disordered context is by establishing order [ 17 ]. The proposed conceptual mental model addresses this issue by organizing emergency nurses’ activities (A, B), prompt acts (C) which represent the first-line management actions and involve a triaging process in order to identify the most appropriate management-action to initiate an immediate lifesaving action; then finally responses (D, E) and this includes the second-line management actions and involves analyzing and planning for further care for the patient if required. These stages may create a more organized working environment.

Implication

Study findings bear several implications. Showing how nurses think in emergency situations, where there is great time pressure and uncertainty, is very important. Indeed, knowing nurses thinking process not only helps to improve patients’ outcomes, it also supports the improvement of the emergency nurses at all levels. Teaching the mental model to newly employed nurses working in emergency departments and critical care units will contribute to their understanding of their own mental processes and limitations. In addition to newly employed nurses, this model could also have implications for anyone practicing emergency care such as paramedics and general nurse practitioners in rural clinics. The theoretical mental model gives clinical educators a practical starting point to develop training and educational methods that elaborate each thinking stage separately, hence, identifying cognitive weaknesses and training nurses to avoid them. This is extremely important for the newly employed nurses who initially require extra support as they obtain their practical experience and combine it with their existing theoretical knowledge. It is also important in assisting experienced nurses in their practice by enhancing self-awareness of their own mental processes and limitations. Highlighting the importance of the theoretical mental model to nurses in emergency situations to support their thinking process may encourage the field to implement formal follow up processes enabling nurses to review their thinking process outcomes. This would contribute to learning opportunities by identifying areas for improvement and gaps in clinical decision making. The model may also be used to develop clinical decision-making tools tailored to the needs of the emergency practice. The study findings have also raised an opportunity for further investigation into the underlying mental processes of nurses’ decision-making under time pressure and uncertainty.

Limitations

Although this study adds valuable information to the body of knowledge, there are several limitations. Firstly, the homogeneity of the sample interferes with the generalizability of the results. Studies involving different nurses from different geographic populations is recommended. Secondly, factors such as confidence and mental capabilities have been found to influence the cognitive process and were not investigated in this study. These factors should be considered in future research. The sample also has included recently employed novice nurses who may lack of adequate experience. Experience is seen to be a critical factor to enhance an individual’s own thought process and decision-making. More studies are recommended in this area of investigation. Finally, the focus of the current study was only to better understand how new graduate nurses process information and initiate actions in an emergency situation characterized by time constraint and uncertainty; more studies are required to investigate the contributing factors underlying errors in initiating actions.

Conclusions

The study provides new insights into decision-making and thinking processes under conditions of time pressure and uncertainty. Newly employed nurses apply System-1 and System-2 thought processes when encountered with emergency situations. System-1 thinking approach was the influencing factor in how decisions were made. Newly employed nurses have relied on the easily accessible contextual information to form an initial impression. They displayed their ability to use minimum information to identify life threatening issues and modulated their actions accordingly. They are more likely to make errors as they decide upon the actions required to perform life-saving measures. The implications of this proposed mental model for emergency nursing practice are: decision-making structure guidance; better cognitive performance in emergency settings in relation to decision-making; and encouragement in the implementation of formal follow up, thus supporting continued improvement in practice to better thought process outcomes. However, the suggested approach requires further studies.

Supporting information

S1 checklist. coreq (consolidated criteria for reporting qualitative research) checklist..

https://doi.org/10.1371/journal.pone.0269624.s001

S1 Appendix. Retrospective think-aloud interview protocol.

https://doi.org/10.1371/journal.pone.0269624.s002

S2 Appendix.

https://doi.org/10.1371/journal.pone.0269624.s003

S1 File. Simulation case.

https://doi.org/10.1371/journal.pone.0269624.s004

S2 File. Trainee answer sheet.

https://doi.org/10.1371/journal.pone.0269624.s005

https://doi.org/10.1371/journal.pone.0269624.s006

Acknowledgments

The author would like to acknowledge Taif University for supporting this study through the University Research Supporting Project number (TURSP-2020/194). The author wishes also to express her gratitude to the participants for their significant contribution. She also wishes to express her thanks for all the simulation unit team members for their significant contribution and help. She could not do this scientific work without their invaluable contributions.

• View Article
• PubMed/NCBI
• Google Scholar
• 9. Croskerry P. Clinical decision making in emergency medicine. Clinical Reasoning in the Health Professions. 4th ed. New York, NY: Elsevier. 2018 Oct 15:285–94.
• 15. Swain J. A hybrid approach to thematic analysis in qualitative research: Using a practical example. SAGE Publications Ltd; 2018.
• 18. Moteri MO. Investigating failure to recognize clinical deterioration cues among less and more experienced nurse participants. Doctoral dissertation , 2016. Monash University.

41+ Critical Thinking Examples (Definition + Practices)

Critical thinking is an essential skill in our information-overloaded world, where figuring out what is fact and fiction has become increasingly challenging.

But why is critical thinking essential? Put, critical thinking empowers us to make better decisions, challenge and validate our beliefs and assumptions, and understand and interact with the world more effectively and meaningfully.

Critical thinking is like using your brain's "superpowers" to make smart choices. Whether it's picking the right insurance, deciding what to do in a job, or discussing topics in school, thinking deeply helps a lot. In the next parts, we'll share real-life examples of when this superpower comes in handy and give you some fun exercises to practice it.

Critical Thinking Process Outline

Critical thinking means thinking clearly and fairly without letting personal feelings get in the way. It's like being a detective, trying to solve a mystery by using clues and thinking hard about them.

It isn't always easy to think critically, as it can take a pretty smart person to see some of the questions that aren't being answered in a certain situation. But, we can train our brains to think more like puzzle solvers, which can help develop our critical thinking skills.

Here's what it looks like step by step:

Spotting the Problem: It's like discovering a puzzle to solve. You see that there's something you need to figure out or decide.

Collecting Clues: Now, you need to gather information. Maybe you read about it, watch a video, talk to people, or do some research. It's like getting all the pieces to solve your puzzle.

Breaking It Down: This is where you look at all your clues and try to see how they fit together. You're asking questions like: Why did this happen? What could happen next?

Checking Your Clues: You want to make sure your information is good. This means seeing if what you found out is true and if you can trust where it came from.

Making a Guess: After looking at all your clues, you think about what they mean and come up with an answer. This answer is like your best guess based on what you know.

Explaining Your Thoughts: Now, you tell others how you solved the puzzle. You explain how you thought about it and how you answered. 

Checking Your Work: This is like looking back and seeing if you missed anything. Did you make any mistakes? Did you let any personal feelings get in the way? This step helps make sure your thinking is clear and fair.

And remember, you might sometimes need to go back and redo some steps if you discover something new. If you realize you missed an important clue, you might have to go back and collect more information.

Critical Thinking Methods

Just like doing push-ups or running helps our bodies get stronger, there are special exercises that help our brains think better. These brain workouts push us to think harder, look at things closely, and ask many questions.

It's not always about finding the "right" answer. Instead, it's about the journey of thinking and asking "why" or "how." Doing these exercises often helps us become better thinkers and makes us curious to know more about the world.

Now, let's look at some brain workouts to help us think better:

1. "What If" Scenarios

Imagine crazy things happening, like, "What if there was no internet for a month? What would we do?" These games help us think of new and different ideas.

Pick a hot topic. Argue one side of it and then try arguing the opposite. This makes us see different viewpoints and think deeply about a topic.

3. Analyze Visual Data

Check out charts or pictures with lots of numbers and info but no explanations. What story are they telling? This helps us get better at understanding information just by looking at it.

4. Mind Mapping

Write an idea in the center and then draw lines to related ideas. It's like making a map of your thoughts. This helps us see how everything is connected.

There's lots of mind-mapping software , but it's also nice to do this by hand.

5. Weekly Diary

Every week, write about what happened, the choices you made, and what you learned. Writing helps us think about our actions and how we can do better.

6. Evaluating Information Sources

Collect stories or articles about one topic from newspapers or blogs. Which ones are trustworthy? Which ones might be a little biased? This teaches us to be smart about where we get our info.

There are many resources to help you determine if information sources are factual or not.

7. Socratic Questioning

This way of thinking is called the Socrates Method, named after an old-time thinker from Greece. It's about asking lots of questions to understand a topic. You can do this by yourself or chat with a friend.

Start with a Big Question:

"What does 'success' mean?"

Dive Deeper with More Questions:

"Why do you think of success that way?" "Do TV shows, friends, or family make you think that?" "Does everyone think about success the same way?"

"Can someone be a winner even if they aren't rich or famous?" "Can someone feel like they didn't succeed, even if everyone else thinks they did?"

Look for Real-life Examples:

"Who is someone you think is successful? Why?" "Was there a time you felt like a winner? What happened?"

Think About Other People's Views:

"How might a person from another country think about success?" "Does the idea of success change as we grow up or as our life changes?"

Think About What It Means:

"How does your idea of success shape what you want in life?" "Are there problems with only wanting to be rich or famous?"

Look Back and Think:

"After talking about this, did your idea of success change? How?" "Did you learn something new about what success means?"

8. Six Thinking Hats 

Edward de Bono came up with a cool way to solve problems by thinking in six different ways, like wearing different colored hats. You can do this independently, but it might be more effective in a group so everyone can have a different hat color. Each color has its way of thinking:

White Hat (Facts): Just the facts! Ask, "What do we know? What do we need to find out?"

Red Hat (Feelings): Talk about feelings. Ask, "How do I feel about this?"

Black Hat (Careful Thinking): Be cautious. Ask, "What could go wrong?"

Yellow Hat (Positive Thinking): Look on the bright side. Ask, "What's good about this?"

Green Hat (Creative Thinking): Think of new ideas. Ask, "What's another way to look at this?"

Blue Hat (Planning): Organize the talk. Ask, "What should we do next?"

When using this method with a group:

• Explain all the hats.
• Decide which hat to wear first.
• Make sure everyone switches hats at the same time.
• Finish with the Blue Hat to plan the next steps.

9. SWOT Analysis

SWOT Analysis is like a game plan for businesses to know where they stand and where they should go. "SWOT" stands for Strengths, Weaknesses, Opportunities, and Threats.

There are a lot of SWOT templates out there for how to do this visually, but you can also think it through. It doesn't just apply to businesses but can be a good way to decide if a project you're working on is working.

Strengths: What's working well? Ask, "What are we good at?"

Weaknesses: Where can we do better? Ask, "Where can we improve?"

Opportunities: What good things might come our way? Ask, "What chances can we grab?"

Threats: What challenges might we face? Ask, "What might make things tough for us?"

Steps to do a SWOT Analysis:

• Goal: Decide what you want to find out.
• Research: Learn about your business and the world around it.
• Brainstorm: Get a group and think together. Talk about strengths, weaknesses, opportunities, and threats.
• Pick the Most Important Points: Some things might be more urgent or important than others.
• Make a Plan: Decide what to do based on your SWOT list.
• Check Again Later: Things change, so look at your SWOT again after a while to update it.

Now that you have a few tools for thinking critically, let’s get into some specific examples.

Everyday Examples

Life is a series of decisions. From the moment we wake up, we're faced with choices – some trivial, like choosing a breakfast cereal, and some more significant, like buying a home or confronting an ethical dilemma at work. While it might seem that these decisions are disparate, they all benefit from the application of critical thinking.

10. Deciding to buy something

Imagine you want a new phone. Don't just buy it because the ad looks cool. Think about what you need in a phone. Look up different phones and see what people say about them. Choose the one that's the best deal for what you want.

11. Deciding what is true

There's a lot of news everywhere. Don't believe everything right away. Think about why someone might be telling you this. Check if what you're reading or watching is true. Make up your mind after you've looked into it.

12. Deciding when you’re wrong

Sometimes, friends can have disagreements. Don't just get mad right away. Try to see where they're coming from. Talk about what's going on. Find a way to fix the problem that's fair for everyone.

13. Deciding what to eat

There's always a new diet or exercise that's popular. Don't just follow it because it's trendy. Find out if it's good for you. Ask someone who knows, like a doctor. Make choices that make you feel good and stay healthy.

14. Deciding what to do today

Everyone is busy with school, chores, and hobbies. Make a list of things you need to do. Decide which ones are most important. Plan your day so you can get things done and still have fun.

15. Making Tough Choices

Sometimes, it's hard to know what's right. Think about how each choice will affect you and others. Talk to people you trust about it. Choose what feels right in your heart and is fair to others.

16. Planning for the Future

Big decisions, like where to go to school, can be tricky. Think about what you want in the future. Look at the good and bad of each choice. Talk to people who know about it. Pick what feels best for your dreams and goals.

Job Examples

17. solving problems.

Workers brainstorm ways to fix a machine quickly without making things worse when a machine breaks at a factory.

18. Decision Making

A store manager decides which products to order more of based on what's selling best.

19. Setting Goals

A team leader helps their team decide what tasks are most important to finish this month and which can wait.

20. Evaluating Ideas

At a team meeting, everyone shares ideas for a new project. The group discusses each idea's pros and cons before picking one.

21. Handling Conflict

Two workers disagree on how to do a job. Instead of arguing, they talk calmly, listen to each other, and find a solution they both like.

22. Improving Processes

A cashier thinks of a faster way to ring up items so customers don't have to wait as long.

23. Asking Questions

Before starting a big task, an employee asks for clear instructions and checks if they have the necessary tools.

24. Checking Facts

Before presenting a report, someone double-checks all their information to make sure there are no mistakes.

25. Planning for the Future

A business owner thinks about what might happen in the next few years, like new competitors or changes in what customers want, and makes plans based on those thoughts.

26. Understanding Perspectives

A team is designing a new toy. They think about what kids and parents would both like instead of just what they think is fun.

School Examples

27. researching a topic.

For a history project, a student looks up different sources to understand an event from multiple viewpoints.

28. Debating an Issue

In a class discussion, students pick sides on a topic, like school uniforms, and share reasons to support their views.

29. Evaluating Sources

While writing an essay, a student checks if the information from a website is trustworthy or might be biased.

30. Problem Solving in Math

When stuck on a tricky math problem, a student tries different methods to find the answer instead of giving up.

31. Analyzing Literature

In English class, students discuss why a character in a book made certain choices and what those decisions reveal about them.

32. Testing a Hypothesis

For a science experiment, students guess what will happen and then conduct tests to see if they're right or wrong.

33. Giving Peer Feedback

After reading a classmate's essay, a student offers suggestions for improving it.

34. Questioning Assumptions

In a geography lesson, students consider why certain countries are called "developed" and what that label means.

35. Designing a Study

For a psychology project, students plan an experiment to understand how people's memories work and think of ways to ensure accurate results.

36. Interpreting Data

In a science class, students look at charts and graphs from a study, then discuss what the information tells them and if there are any patterns.

Critical Thinking Puzzles

Not all scenarios will have a single correct answer that can be figured out by thinking critically. Sometimes we have to think critically about ethical choices or moral behaviors. 

Here are some mind games and scenarios you can solve using critical thinking. You can see the solution(s) at the end of the post.

37. The Farmer, Fox, Chicken, and Grain Problem

A farmer is at a riverbank with a fox, a chicken, and a grain bag. He needs to get all three items across the river. However, his boat can only carry himself and one of the three items at a time. 

Here's the challenge:

• If the fox is left alone with the chicken, the fox will eat the chicken.
• If the chicken is left alone with the grain, the chicken will eat the grain.

How can the farmer get all three items across the river without any item being eaten? 

38. The Rope, Jar, and Pebbles Problem

You are in a room with two long ropes hanging from the ceiling. Each rope is just out of arm's reach from the other, so you can't hold onto one rope and reach the other simultaneously. 

Your task is to tie the two rope ends together, but you can't move the position where they hang from the ceiling.

You are given a jar full of pebbles. How do you complete the task?

39. The Two Guards Problem

Imagine there are two doors. One door leads to certain doom, and the other leads to freedom. You don't know which is which.

In front of each door stands a guard. One guard always tells the truth. The other guard always lies. You don't know which guard is which.

You can ask only one question to one of the guards. What question should you ask to find the door that leads to freedom?

40. The Hourglass Problem

You have two hourglasses. One measures 7 minutes when turned over, and the other measures 4 minutes. Using just these hourglasses, how can you time exactly 9 minutes?

41. The Lifeboat Dilemma

Imagine you're on a ship that's sinking. You get on a lifeboat, but it's already too full and might flip over. 

Nearby in the water, five people are struggling: a scientist close to finding a cure for a sickness, an old couple who've been together for a long time, a mom with three kids waiting at home, and a tired teenager who helped save others but is now in danger. 

You can only save one person without making the boat flip. Who would you choose?

42. The Tech Dilemma

You work at a tech company and help make a computer program to help small businesses. You're almost ready to share it with everyone, but you find out there might be a small chance it has a problem that could show users' private info. 

If you decide to fix it, you must wait two more months before sharing it. But your bosses want you to share it now. What would you do?

43. The History Mystery

Dr. Amelia is a history expert. She's studying where a group of people traveled long ago. She reads old letters and documents to learn about it. But she finds some letters that tell a different story than what most people believe. 

If she says this new story is true, it could change what people learn in school and what they think about history. What should she do?

The Role of Bias in Critical Thinking

Have you ever decided you don’t like someone before you even know them? Or maybe someone shared an idea with you that you immediately loved without even knowing all the details. 

This experience is called bias, which occurs when you like or dislike something or someone without a good reason or knowing why. It can also take shape in certain reactions to situations, like a habit or instinct. 

Bias comes from our own experiences, what friends or family tell us, or even things we are born believing. Sometimes, bias can help us stay safe, but other times it stops us from seeing the truth.

Not all bias is bad. Bias can be a mechanism for assessing our potential safety in a new situation. If we are biased to think that anything long, thin, and curled up is a snake, we might assume the rope is something to be afraid of before we know it is just a rope.

While bias might serve us in some situations (like jumping out of the way of an actual snake before we have time to process that we need to be jumping out of the way), it often harms our ability to think critically.

How Bias Gets in the Way of Good Thinking

Selective Perception: We only notice things that match our ideas and ignore the rest. 

It's like only picking red candies from a mixed bowl because you think they taste the best, but they taste the same as every other candy in the bowl. It could also be when we see all the signs that our partner is cheating on us but choose to ignore them because we are happy the way we are (or at least, we think we are).

Agreeing with Yourself: This is called “ confirmation bias ” when we only listen to ideas that match our own and seek, interpret, and remember information in a way that confirms what we already think we know or believe. 

An example is when someone wants to know if it is safe to vaccinate their children but already believes that vaccines are not safe, so they only look for information supporting the idea that vaccines are bad.

Thinking We Know It All: Similar to confirmation bias, this is called “overconfidence bias.” Sometimes we think our ideas are the best and don't listen to others. This can stop us from learning.

Have you ever met someone who you consider a “know it”? Probably, they have a lot of overconfidence bias because while they may know many things accurately, they can’t know everything. Still, if they act like they do, they show overconfidence bias.

There's a weird kind of bias similar to this called the Dunning Kruger Effect, and that is when someone is bad at what they do, but they believe and act like they are the best .

Following the Crowd: This is formally called “groupthink”. It's hard to speak up with a different idea if everyone agrees. But this can lead to mistakes.

An example of this we’ve all likely seen is the cool clique in primary school. There is usually one person that is the head of the group, the “coolest kid in school”, and everyone listens to them and does what they want, even if they don’t think it’s a good idea.

How to Overcome Biases

Here are a few ways to learn to think better, free from our biases (or at least aware of them!).

Know Your Biases: Realize that everyone has biases. If we know about them, we can think better.

Listen to Different People: Talking to different kinds of people can give us new ideas.

Ask Why: Always ask yourself why you believe something. Is it true, or is it just a bias?

Understand Others: Try to think about how others feel. It helps you see things in new ways.

Keep Learning: Always be curious and open to new information.

In today's world, everything changes fast, and there's so much information everywhere. This makes critical thinking super important. It helps us distinguish between what's real and what's made up. It also helps us make good choices. But thinking this way can be tough sometimes because of biases. These are like sneaky thoughts that can trick us. The good news is we can learn to see them and think better.

There are cool tools and ways we've talked about, like the "Socratic Questioning" method and the "Six Thinking Hats." These tools help us get better at thinking. These thinking skills can also help us in school, work, and everyday life.

We’ve also looked at specific scenarios where critical thinking would be helpful, such as deciding what diet to follow and checking facts.

Thinking isn't just a skill—it's a special talent we improve over time. Working on it lets us see things more clearly and understand the world better. So, keep practicing and asking questions! It'll make you a smarter thinker and help you see the world differently.

Critical Thinking Puzzles (Solutions)

The farmer, fox, chicken, and grain problem.

• The farmer first takes the chicken across the river and leaves it on the other side.
• He returns to the original side and takes the fox across the river.
• After leaving the fox on the other side, he returns the chicken to the starting side.
• He leaves the chicken on the starting side and takes the grain bag across the river.
• He leaves the grain with the fox on the other side and returns to get the chicken.
• The farmer takes the chicken across, and now all three items -- the fox, the chicken, and the grain -- are safely on the other side of the river.

The Rope, Jar, and Pebbles Problem

• Take one rope and tie the jar of pebbles to its end.
• Swing the rope with the jar in a pendulum motion.
• While the rope is swinging, grab the other rope and wait.
• As the swinging rope comes back within reach due to its pendulum motion, grab it.
• With both ropes within reach, untie the jar and tie the rope ends together.

The Two Guards Problem

The question is, "What would the other guard say is the door to doom?" Then choose the opposite door.

The Hourglass Problem

• Start both hourglasses. 
• When the 4-minute hourglass runs out, turn it over.
• When the 7-minute hourglass runs out, the 4-minute hourglass will have been running for 3 minutes. Turn the 7-minute hourglass over. 
• When the 4-minute hourglass runs out for the second time (a total of 8 minutes have passed), the 7-minute hourglass will run for 1 minute. Turn the 7-minute hourglass again for 1 minute to empty the hourglass (a total of 9 minutes passed).

The Boat and Weights Problem

Take the cat over first and leave it on the other side. Then, return and take the fish across next. When you get there, take the cat back with you. Leave the cat on the starting side and take the cat food across. Lastly, return to get the cat and bring it to the other side.

The Lifeboat Dilemma

There isn’t one correct answer to this problem. Here are some elements to consider:

• Moral Principles: What values guide your decision? Is it the potential greater good for humanity (the scientist)? What is the value of long-standing love and commitment (the elderly couple)? What is the future of young children who depend on their mothers? Or the selfless bravery of the teenager?
• Future Implications: Consider the future consequences of each choice. Saving the scientist might benefit millions in the future, but what moral message does it send about the value of individual lives?
• Emotional vs. Logical Thinking: While it's essential to engage empathy, it's also crucial not to let emotions cloud judgment entirely. For instance, while the teenager's bravery is commendable, does it make him more deserving of a spot on the boat than the others?
• Acknowledging Uncertainty: The scientist claims to be close to a significant breakthrough, but there's no certainty. How does this uncertainty factor into your decision?
• Personal Bias: Recognize and challenge any personal biases, such as biases towards age, profession, or familial status.

The Tech Dilemma

Again, there isn’t one correct answer to this problem. Here are some elements to consider:

• Evaluate the Risk: How severe is the potential vulnerability? Can it be easily exploited, or would it require significant expertise? Even if the circumstances are rare, what would be the consequences if the vulnerability were exploited?
• Stakeholder Considerations: Different stakeholders will have different priorities. Upper management might prioritize financial projections, the marketing team might be concerned about the product's reputation, and customers might prioritize the security of their data. How do you balance these competing interests?
• Short-Term vs. Long-Term Implications: While launching on time could meet immediate financial goals, consider the potential long-term damage to the company's reputation if the vulnerability is exploited. Would the short-term gains be worth the potential long-term costs?
• Ethical Implications : Beyond the financial and reputational aspects, there's an ethical dimension to consider. Is it right to release a product with a known vulnerability, even if the chances of it being exploited are low?
• Seek External Input: Consulting with cybersecurity experts outside your company might be beneficial. They could provide a more objective risk assessment and potential mitigation strategies.
• Communication: How will you communicate the decision, whatever it may be, both internally to your team and upper management and externally to your customers and potential users?

The History Mystery

Dr. Amelia should take the following steps:

• Verify the Letters: Before making any claims, she should check if the letters are actual and not fake. She can do this by seeing when and where they were written and if they match with other things from that time.
• Get a Second Opinion: It's always good to have someone else look at what you've found. Dr. Amelia could show the letters to other history experts and see their thoughts.
• Research More: Maybe there are more documents or letters out there that support this new story. Dr. Amelia should keep looking to see if she can find more evidence.
• Share the Findings: If Dr. Amelia believes the letters are true after all her checks, she should tell others. This can be through books, talks, or articles.
• Stay Open to Feedback: Some people might agree with Dr. Amelia, and others might not. She should listen to everyone and be ready to learn more or change her mind if new information arises.

Ultimately, Dr. Amelia's job is to find out the truth about history and share it. It's okay if this new truth differs from what people used to believe. History is about learning from the past, no matter the story.

Related posts:

• Experimenter Bias (Definition + Examples)
• Hasty Generalization Fallacy (31 Examples + Similar Names)
• Ad Hoc Fallacy (29 Examples + Other Names)
• Confirmation Bias (Examples + Definition)
• Equivocation Fallacy (26 Examples + Description)

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16 Critical Thinking Examples in Real Life

What is critical thinking.

While making your academic assignments or thesis, you are required to do some research and analyze various things, or for making a career decision or any other decision you are required to think of all pros and cons of that decision. Well, the most important thing that helps us to effectively take these decisions is what we call critical thinking. Critical thinking is very important in both personal and professional life. The process of critical thinking involves the analysis of the various facts and figures in a particular situation before straightaway acting on that situation. Critical thinking demands keen observation, creativity, problem-solving skills, which helps the individual to thoroughly evaluate the gathered information and then use this available information as a guide to making accurate decisions. From doing academic works or regular activities to solving various large scale problems, critical thinking is required in everyday life. In this article, we will learn about some real-life examples where critical thinking plays an important role.

Critical Thinking Examples in Real Life

1. critical thinking in problem solving.

Suppose your manager asks you to find an effective solution to a problem that is affecting the business. What would be your first step? Like most people, you may also start looking for potential solutions to deal with that situation. Well, one requires the use of critical thinking here. Before looking for the solution one needs to take a step back and try to understand the cause of the problem first. One should ask for the opinions of the other people that how does this particular problem impact them and the overall business. If you arrive at a solution, you should not only just rely on one solution, instead, you should always have various backup plans in case the first solution does not work as expected. Most people feel that they are great at problem-solving, but if one is not following all these above discussed steps before making a final judgement, he/she is not a critical thinker. Critical thinking allows people to find the best possible solution to any problem. Critical thinking is an important factor of problem-solving skills, one needs to look at any situation from multiple perspectives because in some cases, your decisions not only impact you but also the people in your surrounding.

2. Critical Thinking in Analysing Risks

Risk assessment is another important factor, which requires the use of critical thinking. Risk assessment is required in various sectors, from children analysing the impact of eating junk food on their health to large businesses in analysing the impact of certain policies on the growth of the company. Let us understand the implication of critical thinking in analysing the risks with some examples.

3. Critical Thinking in Data Analysis

Whether analysing the performance of the children in the schools or analysing the business growth of a multi-national company, the skill of data analysis is very crucial. In today’s era, almost every sector demands experts that can accurately evaluate the available data or information and draw out effective conclusions from it. With the rise in technology, the various tasks of the data analysis such as finding profit and loss, creating balance sheets, and issuing invoices are done with the help of various software, but it does not mean that human skill is not required. Various kinds of software can just convert a large amount of data into some simpler and readable format, but it is the critical thinking of the humans that is required to effectively interpret the data and apply the obtained insight for the benefits. The data analysis can even help us to estimate the future trends and potential risks of taking any decisions.

4. Critical Thinking in Hiring Employees

The ability to objectively view any situation without getting influenced by your personal beliefs or thoughts is one of the important characteristics of critical thinking. In business, the hiring managers require critical thinking to evaluate a large number of resume’s to choose the suitable candidates for the required position. Critical thinking here enables the hiring managers not to hire a candidate on the basis of various factors like gender, age, religion or country, these factors may influence the hiring managers unconsciously. The hiring manager may tend to choose the candidate on his/her subjective beliefs if he/she does not use critical thinking. Hence, critical thinking can help HR’s to hire the best employees that may eventually lead to the growth of the company.

5. Promoting the Teamwork

In a team, every individual is unique and has his/her different ideas to tackle the proposed problem. It is the responsibility of the team leader to understand the perspective of each member and encourage them to work collectively to solve the common problem. You may find the opinion of the other members of your team as ineffective, but instead of straightway denying their opinions one should logically analyse their suggestions and try to put your point of view regarding the problem in an effective and calm manner. If the team leader does not use critical thinking, instead, he/she boost his/her opinions on others, the team is sure to collapse.

6. Critical Thinking in Self-Evaluation

Critical thinking plays a major role in self-evaluation. The knowledge of critical thinking skills allows you to accurately analyse your performance by controlling various subjective biases. People should always evaluate their reactions towards any situation and the way they think, this may help them to get a deep insight into their thought processes, hence improving their thinking abilities to take accurate decisions. Self-evaluation is very important in professional life too. Suppose your manager has set a new target for the company. Every employee is thus required to analyse his/her contribution to the company and try to accomplish the set target. If you know your contribution to the company, it will help you to analyse your performance, and you can try to improve your performance in the areas where you lag.

7. Critical Thinking in Choosing the Career

Almost all of us face various dilemmas in our lives such as choosing the stream, the type of job, choosing between the regular college degree or the online programme. Whatever you choose, every option has its pros and cons. However, critical thinking allows us to accurately weigh the positives and negatives of each option and choose the one that offers more benefits than drawbacks. The best way to do this is to make a list of the pros and the cons and then analyse. Well, this is not just limited to choosing the career path, it can be used in other situations also such as professionally, and financially. One can list the pros and cons of selecting to work in a specific company or choosing the right insurance plan. It is often seen that our choices are greatly influenced by the choices of our friends or known, but one should understand that every individual’s beliefs, desires, and ambitions are different so, if the particular carrear or job is best for the others it does not mean that it would be the best option for you also. Hence, to choose the right carrear path, one requires critical thinking.

8. Critical Thinking in Time Management

Time is the most valuable asset that we have, hence utilizing it appropriately is very crucial. Critical thinking in time management helps you to wisely plan your schedule according to the importance of the particular task or the activity. For example, if the task to which you devote most of your time, is not giving you much return then you need to reconsider your schedule and should devote more time to the tasks that give you high returns.

9. Critical Thinking in Analysing the Fake News

Suppose, one of your friends shares a piece of news with you. Do you bother to analyse that whether this piece of news is real or not? Many of us just believe in the news and shares this with others too without thinking that this can be fake news too. A study conducted by Stanford University showed that around 82 per cent of the teenagers failed to distinguish between the real news and the advertisement with the ‘sponsored content’ label. This problem arises because the standard education curriculum does not emphasise much on critical thinking skills much because of the assumption that critical thinking is inbuilt in every person. By introducing certain lessons or activities that may help to increase the knowledge or overall thinking skills, the critical thinking of the children can be improved. Well, it is also seen that not only children, but adults also fall for these fake news and articles that circulate on various social media platforms. Before believing any piece of information, one should think of various questions like the source of the publication, the intention of the article, the author of the article, and the agenda behind the article. Critical thinking helps us to precisely evaluate any information before straightway believing it.

10. Critical Thinking in Distinguishing between Right and Wrong

Most people, especially teenagers are very much conscious about what their friends or relatives think of their behaviour. You may have had been through the situation, wherein if your friends think that certain behaviour is cool then you start acting in that way to fit in your friend’s circle without even considering that what you are doing is good or bad, and is your actions are related to your beliefs or not? One should understand that if a certain behaviour seems cool to some people, it may also seem bad to some others. One should not change his/her actions depending upon the approval of certain people, rather one should look at the broader aspect and should deeply analyse that whether their actions are morally right or wrong.

11. Critical Thinking in Decoding Fashion Trends

Nowadays, some people are so crazy about following the latest fashion trends, they start following every trend that some popular actor, actress, or fashion influencer suggest. If you are a critical thinker you may have had thought of the questions like why the particular trend that was so popular a few years back seems foolish now? why does a particular trend that does not even look good is so popular? Do the particular fashion trend that suits the other person suits yourself or not? Critical thinking helps people from falling victim to the bandwagon fallacy; it is fallacy in which people starts believing a particular thing or idea as good or bad if the majority of the population thinks so. Fashion trends are a common example of bandwagon fallacy.

12. Critical Thinking in Choosing the Suitable Diet and Exercise

You must have heard of various types of diets such as the Keto diet, Whole 30 diet, Gluten-free diet, Vegan diet and so on. It seems complex to choose the diet that is best for you. What people usually do is that they search online, go through several videos and choose the diet that showed the best results to the person in the video. Well, this is not the right approach, choosing the best diet for yourself requires critical thinking. People who use critical thinking evaluate the pros and cons of the particular diet on their own body, they generally ask about the suitable diet from professional dieticians rather than just following the advice of a random person online. Like choosing a suitable diet, choosing a suitable exercise also demands critical thinking. For example, What are your goals? How can you achieve this? At what time you can do exercise? Do you have any injuries that may get affected by the particular exercise? People who use critical thinking tend to ask all these questions, and then by utilizing the knowledge they have and the following routine for a few weeks, and by analyzing the results they are getting from it, they finally plan a proper schedule for them.

13. Critical Thinking in Online Shopping

In today’s digital era, online shopping is preferred by most people. However, there are various tactics and psychological tricks such as the anchoring effect , Stroop effect , and Serial position effect that are used by the various e-commerce websites, which makes the customers buy more things or things that they don’t even need. Critical thinking can help people to smartly buy items without falling victim to all these effects or tactics. While making the purchase you should focus on the price that you are paying for the particular item rather than the discount you are getting on that item because the chances are that the price that you are paying for that item is not worth paying even after the discount.

14. Critical Thinking in Job Search

Critical thinking plays an important role in the Job search. If you are applying for a job, you may consider the following points to get the desired job.

Use of Keywords in Resume: One should always understand the job post and its requirements before straightaway applying for the job. It is important to update your resume according to the job and add some keywords (mentioned in the job requirements) into your resume to get the job. If you possess some critical thinking skills such as problem-solving, analytical, communication, or creativity skills, it is better to put that in your resume. However, one should always restrain from adding any random critical thinking skills that you do not possess.

Cover Letter: Hiring managers receive hundreds of resumes daily, hence the chances that they will read every resume are quite less. Well, you can make your resume different from others by adding a good cover letter. You can add some of the critical skills that you have to your resume, it is better to explain a little about the tasks or activities where you showed these skills in your previous jobs or work experiences rather than just simply writing the skill. This assures the recruiter that you are not randomly writing the skills and you possess these qualities.

Interviews: Nowadays, some interviewers present the interviewees with hypothetical stories to check their critical thinking skills. You may be asked to explain what you think of the given situation or your first reaction after looking at the given image. You are required to solve any random problem, and then you have to explain to the recruiter about your thought processes. The interviewer here is more focused on the way you reach the conclusion rather than the conclusion itself. Your thought process helps the interviewer to analyse and evaluate the way you approach various problems

15. Critical Thinking While Driving

Imagine you are driving on a busy road and your phone starts ringing. It’s an urgent call that you have to pick. What would you do? Would you pick up the call and risk yourself into an accident or stop your car on the roadside to take the call. Critical thinking helps you to make accurate decisions while driving, it includes finding the right place to park your car, analysing whether you can pass the car through that narrow street or not, or how to handle if any animal suddenly comes in front of your car. Hence, critical thinking is must require skill in driving.

16. Critical Thinking in Business

Critical thinking is one of the most important things that the owner of the business needs to possess. One has to make several important decisions, effectively communicate with the clients, hire suitable employees, take certain risks, and deal with several ups and downs in the business, and much more; all these things require critical thinking.

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Great post! I’ve been trying to apply critical thinking to my life, and these examples are a great way to start.

critical thinking is what anyone of us should have in spoiled world

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Psychological Coping in Emergencies and Crises

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This entry describes key areas where your performance and life can be affected by stress and worry associated with emergencies and crises. It also provide hints and tips to cope with such stress and worry.

Scope and Application

Types of emergencies and crises.

There are three types of crises that we may experience in humanitarian response:

• Sudden and unexpected (very little warning if any and, usually, beyond the institution's control, e.g. IED explosion);
• Smoldering crises that take time to build up and the warning signs are usually ignored, e.g. financial crises, drought; and
• States of high alert where there is a substantial threat level and/or there is an ongoing conflict which may or may not include the implementation of a peace treaty including disarmament.

There are three stages to a crisis: pre-crisis, crisis and post crisis. We tend to focus mainly on the middle stage but it is important to think about and plan for the other two.

Stress and worry

Working in any of the above can lead to stress and worry.

The impact of stress and worry

Memory: Your memory system has a number of components including short term and long term memory. A significant part of the space in your short term memory system will be taken up by worry if you become too concerned about an issue.

Attention: If you are too stressed or worried, then you may also have problems with your attention. You may focus on the wrong issue or spread your attention too widely and your biases may have the upper hand, paying attention to what you prefer as opposed to the real issue.

Thinking:  It is important to be thinking at the right level. There are four levels at which we can work:

• Level 1: Downloading - We are likely to simply do what we did before in similar situations without acknowledging that the current one is different.
• Level 2: We note that the situation is different but we repeat what we did before.
• Level 3: We acknowledge the newness of the situation and adapt what we did before.
• Level 4: We realize that this is a brand new situation and work from high level rules and principles to create a response (Otto Scharmer).

When we are too stressed and worried, we can conduct Level one or Level two thinking that is not needed. In emergencies, we need to operate at level three or four.

Our decision-making can also be faulty. We need to balance emotions and logic for each decision. If you feel that there is an imbalance, simply silently saying, "I need a balance between logic and emotion" can be enough.

We can improve our memory, attention and thinking by firstly making sure that we are breathing properly (12-18 breaths per minute). Taking a break (even five minutes) to do some physical activity can help.

Double check your decisions and actions with a colleague. Remember, unless it is in the early stages of a crisis, that you usually have more time than you realize. Seek more help than usual from your colleagues.

Critical Thinking Mode

• This is the ability to think rapidly while holding facts and views as they come in without reaching an early conclusion about what type of crisis you are facing. These questions may help.
• Rapid assessment: what are the available facts? What else do you need to know about? Who do you need to work with? Who are the nominated leaders? What is their state of mind? Any biases?
• Have you really identified the core issues? Double-check.
• What immediate actions should you take?
• How will you keep gathering and collating information?
• Stop and review the impact of the actions.
• What more is needed - actions / information?
• Ensure that the physical and social needs of crisis teams are being met, e.g. having food and drink available, ensuring that people sleep at least five hours a night.
• Post-crisis: time off, reflections, lessons learnt, and follow-up actions.

(Ref: Leadership in Unconventional Crises, Lagadec)

The ability to suppress emotions is an important skill to have so that you can function well in a critical incident or emergency. However, total suppression of emotions can have a negative impact because of the high level of self-monitoring that is required to be able to suppress.

It is important to acknowledge the emotion and then suppress it until there is a more appropriate moment. It is important to release the emotion as soon as possible, otherwise there could a negative cumulative aftereffect. There may be moments when you could be volatile, be aware of this and make sure you walk away and/or let others know that you need some time away from the response.

You could feel panicky and find it hard to breathe. Stop, walk away and take some slow deep breathes. Try to just focus on your breathing until you feel calm. Here are some breathing exercises that you could try.

You should be taking 12-18 deep breaths per minute. You can check by placing one hand on your upper chest and the other hand on your abdomen. If you are breathing properly there should be regular movement of your upper and lower chest. If you are not, then it is likely you are breathing in a shallow way. It is important to practice regular deep breathing. This will help you think and act more constructively. Here are some exercises:

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• Your thinking, decision making, emotions and body will be affected by the stress and worry of being in an emergency or crisis. This is the case, regardless of how experienced you are.
• It is important to be aware of how this can affect your performance and take positive steps to address possible difficulties.
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This 1 Hack From A First Responder Will Keep Your Head Cool In An Emergency

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Do you know how to stay calm during an emergency?

Too often, we buckle under the pressure and panic. Take it from an expert who has experienced literal life-or-death stakes. Ryan Fields-Spack is currently the first responder wellness lead at FirstNet, a nationwide communications network for first responders. But before that, he spent 25 years working as a firefighter and paramedic and leading teams in emergency services. He’s seen the difference between fire department chiefs who stayed calm in emergencies and those whose yelling and nerves led everyone else to panic.

When “the person that was in charge didn’t control the situation, everything else around them got worse,” Fields-Spack recalled to HuffPost. “I saw that moment when I was 18 years old [working as a firefighter], and I said, ‘You know what? I just need to find a way to get above this.’”

For Fields-Spack, this meant studying psychology and meditation to develop what he calls a “neutral moments theory” to tackle any moment that requires intense focus, clarity and decisive thinking. He’s used and taught it to first responders, but he’s also used it in everyday emergencies that crop up in parenting and with corporate jobs, too.

“If you can bring yourself into a neutral moment, into a present-moment state of mind, and not worry about what’s happening before, what’s happening after,” then you will “be able to survive and thrive in that situation,” he said.

You may not face the same stakes as a first responder, but you can learn how to stay calm and clear-headed like one, no matter what kind of personal or professional emergency you face. Here’s how:

How The ‘Neutral Moments Theory’ Works

Fields-Spack said getting to a neutral headspace requires both a mindset shift and some practical tools you can use before a big day or when you feel your heart start to race:

1. First, choose to believe that people are not rooting for you to fail.

Worrying what other people think of us can prevent us from performing our best. Whether you’re giving a toast at a wedding or presenting your ideas to higher-ups at work, make the conscious choice to believe people feel neutral about the outcome of your performance.

“Think about the fact that the people that are there watching you ... or interviewing you — at absolute worst — they’re truly neutral in how well you perform,” Fields-Spack said. “But most times, people really want the best for you, and they don’t have any ill will.“

Psychology backs up why aiming for neutral can be a simpler and more effective way to cope when our negative brains want to jump to the worst conclusion.

“It’s common for our brains to imagine the worst-case scenario in stressful situations, almost as a way to prepare ourselves for anything. This can lead to a cognitive distortion called ‘mind reading’ where we assume others are thinking poorly of us,” said Shannon Garcia , a psychotherapist at States of Wellness Counseling based in Illinois and Wisconsin.

“Instead, assuming that people are neutral about us can be really helpful. It creates space in our minds and alleviates some of the anxiety,” Garcia said.

2. Use meditation as a tool to lower your anxiety.

Sometimes, you cannot ignore the stressful stakes — especially when everyone is counting on you to succeed or “save the day,” Fields-Spack said.

That’s when Fields-Spack turns to meditation to get back to his neutral. He does this in the morning before work, and he also does this during an active emergency when he starts to feel anxiety.

Meditation “trains your brain, just like you do reps in the gym to build your muscles,” Fields-Spack said. “It builds reps in your brain to notice when you are thinking about something else, or for me, when I’m at that cardiac arrest call, to notice when my mind is starting to wander to being scared, acknowledging that and coming back to what I’m trying to do.”

In a 2017 review of 45 studies on meditation, the mindful breathing practice was found to lower raised blood pressure and heart rates in a range of populations.

If you can, “do two minutes of meditation before you get out of bed in the morning,” Fields-Spack said. There are a variety of meditation exercises you can try, but it also doesn’t need to take too long.

A few seconds of mindful breathing can also help, Fields-Spack said. So the next time you are feeling the butterflies in your stomach, “relax your fist, drop your jaw [open], and then take one mindful, deliberate, focused, deep breath” in and out, he recommended.

3. Do a mental rehearsal.

Preparation is the key to feeling confident in your capabilities and staying cool-headed amid chaos. When Fields-Spack would get the call that he was acting lieutenant for a shift, he would immediately run through a best-case scenario of what he would say and do in certain emergencies.

“I literally speak out, either whispering to myself or speaking out loud, the radio calls that I’m going to make ... and I make sure that it’s very specific and right in the way that it should be done all the way through that entire situation,” he said.

Rehearsing scenarios in “non-threatening environments” is important to the success of Fields-Spack’s technique, said Alicia Velez , a licensed clinical social worker based in Brooklyn, New York.

“Getting the muscle memory to perform on autopilot without the emotional overwhelm is [a] technique of performance psychology,” she said.

4. Lower the anxiety in the room with how you deliver news.

During an emergency, you can either start barking orders or you can adopt a neutral tone of voice, so you do not stress out everyone else. Choose the latter.

Fields-Spack gave an example of responding to a grandfather’s cardiac arrest. When he gets to that kind of scene, the family may be frantic and scared, so he purposely addresses them “calmly in a monotone voice.”

“If I were to come forward with a high octave, speedy cadence in my voice, and having everybody else kind of jump in, that could cause everybody else to elevate to my level,” he said.

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Speaking with a neutral tone also “buys you time to now think and cohesively continue to make the plan in your head,” he said.

So the next time you encounter a minor emergency like a child falling and scraping their face, stay neutral in your demeanor. “One parent would be very scared, and the child latches on to that and raises up in that anxiety level,” Fields-Spack said of his experience in this situation. But if you speak confidently and calmly, “that immediately does the same for the kiddo.”

When we’re not preoccupied with what others might think of us and we can stay present and focused, we are more likely to be better leaders in a crisis.

“It’s going to be those people that can harness this neutral moments theory, that can harness the capability of guiding other people around them in a calm, confident, cohesive manner that are going to be the ones that drive us forward in society,” Fields-Spack said.

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