critical thinking in emergency situations

The Current State of Critical Thinking in EMS

Critical thinking is not something that one can just begin to do, writes Radu Venter It is a skill that must first be taught, developed over time and regularly maintained.

Emergency medical services (EMS) journals regularly discuss a lack of critical thinking evident in paramedics and how this deficiency is a significant flaw in the profession. Some provide tips and tricks to paramedics looking to develop their critical thinking. Others outline examples of mindsets to follow and biases to avoid. These articles stand by the need for further critical thinking training in EMS, but there are some significant absences that limit their ability to assist practitioners seeking to develop their skills.

Before continuing, we must ask whether critical thinking is a valuable skill for paramedics. Is there a benefit to having paramedics make decisions on their own? Should we instead have them strictly follow flowcharts in patient assessment, initial treatment and prompt transport to a hospital where a doctor can oversee definitive care? Alternately, do we want more basic practitioners to follow the flowcharts and those of higher levels to think critically?

• Critical Thinking, Part One
• Critical Thinking, Part Two
• EMS Providers Use Detective Skills to Solve Case

The current system is largely based on the third option. Paramedics working at advanced levels are expected to be able to critically think. Certain treatments available to these practitioners may be detrimental to the patient, so it falls on the practitioner to assess, reason and treat appropriately. Paramedics working at a more basic level do not have such expectations. Their training encompasses a more limited scope, prioritizing treatment of only more severe conditions. While critical thinking skills may be a goal of advanced care education, at the basic level, the goal is to create technicians. Technicians prioritize practical skills, with less focus on the theoretical. Thus, it is possible to educate a technician rapidly — basic life support programs are thus much shorter. As explained by Daniel Limmer in his EMS World article, “A technician is not expected to use high levels of reasoning skills. Technicians are strictly protocol driven and respond in a specific way when a certain group of signs and symptoms appear.” 1

Why, then, is there all this frustration with a lack of critical thinking in our profession, even with practitioners working at the basic level? The simplest answer is that when the practitioner aspires to the next level of training, critical thinking becomes more important. Unfortunately, to become an advanced level practitioner, the technician must then re-learn a fair amount of their practice. The second reason critical thinking is necessary for all paramedics has to do with the fluidity of patient assessment and treatment. Every skill performed requires an element of critical thinking. The practitioner must be able to select an appropriate diagnostic to perform or therapy to administer. They must then be able to verify the information received or confirm the therapy was effective. Kelly Grayson supports this point, noting that our current focus is more on what skills paramedics can perform, rather than the underlying knowledge necessary to determine when the skill is required and the ability to perform it proficiently. 2 A further avenue of exploration is whether the skill was even necessary in the first place.

Further, paramedics must be able to determine which algorithm for patient treatment will provide the greatest benefit. They must also be able to identify treatment priorities, and which hospital is most appropriate for transport. Finally, there is no effective flowchart for the patient who is suffering from a serious medical condition and wishes to stay at home. Paramedics of any ability level forced to operate in these novel situations without clear directions must then be able to think through the situation and work through the problem.

Two Elements of Critical Thinking

Current EMS articles on how to develop critical thinking fall into the trap of providing guidelines without going into enough depth. Scott Cormier’s two-part article on critical thinking provides a few examples of approaches to critical thinking as well as biases to avoid. 3,4 Unfortunately, they do not touch on the foundation of critical thinking, such as the traits of a good critical thinker, or provide examples to the reader to be able to apply these approaches in their own practice.

Others are more mechanical in nature than cognitive. In Daniel Limmer’s article, he states that practitioners should aspire to be clinicians instead of merely technicians. Where a technician identifies a symptom and works to treat it, a clinician strives to obtain a complete picture of the patient through a thorough assessment and the use of a differential diagnosis, prior to initiating a treatment. Performing thorough assessments of the patient, prioritizing focus on immediate threats to airway, breathing and circulation, and creating a differential diagnosis do not require as much critical thinking as might be expected.

I would suggest that a clinician’s approach has less to do with their ability to critically think, but more to do with thoroughness. In the example Limmer provides, the only difference between a technician and a clinician is the completion of a more thorough assessment that leads to a different diagnosis and, therefore, a different treatment plan. Though creating a differential diagnosis involves elements of critical thinking, it can also be a largely mechanical process — paramedics can easily memorize medical conditions to rule out in the case of a patient presenting with a specific complaint. Of the six steps suggested, only the last two involve critical thinking. Unfortunately, these are the shortest steps in the article. The best example I was able to discover is Rom Duckworth’s article, urging practitioners to assess sources of information for accuracy, validity, and a lack of bias, while also questioning currently-held beliefs. 5 This article focuses on the cognitive skills inherent in critical thinking, avoiding the mechanical pitfalls other articles fall into. However, like the other articles, it is very brief and does not provide examples for practitioners to either follow or practice.

The second major flaw underlying these articles is the assumption that the readers have enough background knowledge of the topic in order to be able to make critical decisions. For example, students in an advanced care paramedic class are asked to create a treatment plan for a cardiac complaint. The patient has sudden onset chest pain, radiating to the left arm, as well as significant pitting edema to upper and lower extremities. The patient also has a significant cardiac history. At the chest, wheezes are auscultated. Several students in the class treat the patient with salbutamol and ipratropium bromide, working to improve air entry and decrease wheezing through bronchodilation. A subsequent discussion introduced the existence of cardiac wheezes, caused not by bronchospasm, but by the presence of fluid in the lungs due to diminished cardiac output. The therapy selected by the students would be minimally effective at best, potentially detrimental to the patient at worst.

Reflecting on this experience, are the students at fault for not determining the patient’s wheezing to be cardiac in origin? Prior learning at the primary care paramedic level focused on treating wheezing as a symptom. Little focus was given to other potential causes of wheezing and treatment plans had a linear approach. Wheezing at that level is an automatic indication for nebulizer therapy.

The flaw lies not in a lack of critical thinking, because there was no room for the students to critically think. The assessment revealed wheezing, the students presumed that it was caused by bronchospasm, and then followed the appropriate protocol. The issue is that the students lacked enough background knowledge to understand the anatomy and physiology of the lungs and the pathophysiology of cardiac wheezing. A critical thinker with this background knowledge would have been able to determine the cause of the wheezing, weigh the benefits of available treatments and choose to initiate or withhold treatments based on the information given to them.

The Next Step

Critical thinking is not something that one can just begin to do. It is a skill that must first be taught, developed over time and regularly maintained. It is a combination of traits that one must possess and processes that must be developed and followed. A critical thinker must be sufficiently open-minded to other ideas and be willing to challenge current knowledge and experience.

This skill should be introduced at the earliest level possible, to benefit practitioners from the beginning of their career. Alongside critical thinking, a foundation of strong clinical knowledge must be present to allow for effective decisions to be made.

1. EMSWorld. Beyond the Basics: The Art of Critical Thinking Part 1 [Internet]. Emsworld.com; April 2008 [cited 2020 Jul 21]. Available from: https://www.emsworld.com/article/10321160/beyond-basics-art-critical-thinking-part-1 .

2. EMS1. EMS 2.0: Critical Thinking in Prehospital Training [Internet] EMS1.com; Oct 2009 [cited 2020 Jul 21]. Available from: https://www.ems1.com/ems-products/education/articles/ems-20-critical-thinking-in-prehospital-training-eCjskymt7gQYBFLe/ .  

3. JEMS. Critical Thinking: Part 1 [Internet]. JEMS.com; May 2017 [cited 2020 Jul 21]. Available from: https://www.jems.com/2017/05/15/critical-thinking-part-one/ .

4. JEMS. Critical Thinking: Part 2 [Internet]. JEMS.com; May 2017 [cited 2020 Jul 21]. Available from: https://www.jems.com/2017/05/15/critical-thinking-part-two/ .

5. EMS1. 5 Critical Thinking Skills Crucial to EMS Professional Development [Internet]. EMS1.com; August 2017 [cited 2020 Jul 21]. Available from: https://www.ems1.com/ems-management/articles/5-critical-thinking-skills-crucial-to-ems-professional-development-fQIz2bctBpYHktUP/ . 

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• Educational advances in emergency medicine
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• 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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Cognitive skills of emergency medical services crew members: a literature review

• Martin Sedlár   ORCID: orcid.org/0000-0003-1512-2740 1  

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Situation awareness and decision making, listed in non-technical skills taxonomies, are critical for effective and safe performance in high-risk professions. These cognitive skills and their behavioral markers have been studied less in emergency medical services (EMS) crew members. This paper aims to review the existing literature and identify important aspects and behavioral markers of situation awareness and decision making in EMS crew members – those who work in the role of prehospital emergency care providers – and to synthesize findings as a basis for developing a rating and training tool.

The search for relevant articles was conducted using electronic databases, reference lists of relevant reviews and included articles and personal collection of articles. The selection process based on the PRISMA statement yielded a total of 30 articles that met the eligibility criteria. Their findings were qualitatively synthesized using the structured approach, informed by the already known structure: situation awareness and its elements (gathering information, interpreting information, anticipating future states), decision making and its elements (generating and considering options, selecting and implementing an option, reviewing outcome/decision). Moreover, the element of maintaining standards also emerged as highly relevant for cognitive skills.

This review found an increased research interest in the non-technical cognitive skills of EMS crew members. The majority of included articles’ research designs were qualitative, then mixed, Delphi, and quantitative. It revealed several specifics of cognitive skills, such as EMS crew members need to holistically assess a wide range of cues and information, to make various health- and safety-related decisions and take EMS standards into account. However, there was only a limited number of observable markers of cognitive skills, such as acts and verbalizations, that could be considered as examples of good behavior. In addition, findings indicate a lack of articles focused on mass-casualty incidents and the interconnection of cognitive skills with other non-technical and medical skills.

Further research is needed to get a more comprehensive view of behavioral markers of cognitive skills and to develop a rating and training tool to improve EMS crew members’ cognitive performance.

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Situation awareness and decision making are paramount for emergency medical services (EMS) crew members in encountering and managing various routine and non-routine situations [ 1 ] with high stakes, complexity, dynamic changes, multiple stimuli, uncertainty, stress, and the high likelihood of being error-prone [ 2 ]. These cognitive skills are on the list of key non-technical skills. If they are satisfactory, they enable safe and quality prehospital emergency care [ 3 , 4 , 5 ]. Since human error is in the spotlight as the main contributing factor in poor safety outcomes [ 6 ], the significance of studying cognitive and other non-technical skills has become more apparent. It is demonstrated in skills taxonomies, behavior rating tools, and skills trainings [ 7 , 8 , 9 , 10 , 11 ].

Situation awareness, defined as knowing what is happening in the environment, is based on three elements: gathering information, interpreting information, and anticipating future states [ 3 , 12 ]. Sometimes the term ‘situation awareness’ interchanges with the term ‘situation assessment’ [ 13 ]. A comparison of theories suggests that both terms relate to the understanding of the situation and have analogical cognitive processes [ 12 , 13 , 14 ]. For that reason, these terms are here used together under the category of situation awareness. Considering the interconnection between situation awareness and decision making [ 1 , 15 ], situation awareness is the foundation for decision making. The non-technical skills category of decision making – simply viewed as reaching a judgment or choosing an option – contains four elements: situation assessment/defining problem, generating and considering options, selecting and implementing an option, and outcome review [ 3 ]. As seen, decision making goes beyond the act of the decision itself and situation assessment represents the first step in making decisions [ 13 ].

The defined cognitive skills can be incorrectly confused with medical and technical skills. Although both skills are cognitive in their essence – requiring a form of cognitive activity – indeed they differ. Medical and technical skills refer to specific elements of medical diagnosis, treatment, and the physical procedures thereof [ 16 ]. In other words, they are about using medical expertise, drugs, and equipment [ 11 ]. In contrast, non-technical cognitive skills are conceptualized as general skills [ 17 ], referring to diverse situational elements that must be perceived, monitored, assessed, and decided upon, without the need for manual dexterity. Despite the difference, non-technical skills complement technical skills [ 3 ]. Besides, there is evidence of their correlation [ 18 , 19 ].

Cognitive skills and their individual processes have been scrutinized predominantly in naturalistic decision making and expertise research [ 20 ]. In general, they are harder to be directly observable in behavior, compared with social skills, because they occur primarily in the brain. However, the non-technical skills movement, which emphasizes the behavioral level of skills, claims that situation awareness and decision making can be inferred from some observable behavior, such as specific actions and verbalizations [ 21 ].

So far, the existing literature summaries has not brought enough details about cognitive skills in EMS crew members, and not at all about their behavioral markers. This shows a paucity of research on non-technical cognitive skills, expertise, and safety, which would assist in improving performance in the EMS field. Such research is also needed as each medical specialty has its specifics related to the personnel and work environment, and it is not correct to simply apply findings from one specialty to another.

This paper looks closer on cognitive skills, it aims to review the existing literature and identify important aspects and markers of situation awareness and decision making in EMS crew members – those who work in the role of prehospital emergency care providers – and to synthesize findings as a basis for developing a rating and training tool.

Search method

This literature review utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement [ 22 ] and the Cochrane Handbook for Systematic Reviews of Interventions [ 23 ] to ensure methodological accuracy. Familiarization with the relevant literature on non-technical skills, naturalistic decision making, and expertise informed a process of creating the best search strategy, which would produce a limited number of irrelevant records and a multitude of relevant records. This process required the iterative cycle of searches using various synonyms and very close terms that were in line with the review aim. The final search strategy using Boolean operators contained the terms related to two main concepts: non-technical cognitive skills of situation awareness and decision making, and EMS crew members. The search for relevant articles was conducted in December 2018, without any publication date limitations, using electronic databases and additionally by hand. More details about the search strategy and information sources are given in Table  1 .

Selection process

Relevant articles had to meet the inclusion/exclusion criteria (see Table 1 ), encompassing key aspects and markers of non-technical cognitive skills applicable in EMS crew members. The first two criteria (articles written in English and peer-reviewed articles) were applied already in searching databases. The inclusion of only peer-reviewed articles was used as the quality indicator of articles. The search was limited to article titles and abstracts, but this was not possible in each database (Web of Science allows searching only ‘topics’, which includes titles, abstracts, keywords together – the same applies to Science Direct). After importing records into the reference manager Mendeley and removing duplicates by software and by hand, titles and abstracts were screened, and full texts of potentially relevant articles were retrieved. Additional full-text articles were identified through other sources, i.e., reference lists of relevant reviews [ 4 , 24 , 25 , 26 , 27 , 28 ] and included articles, and personal collection of articles. Two reviewers independently reviewed 30% of records and full texts for eligibility; disagreements were resolved by discussion. This served to eliminate biases and take a consensual view on the selection process. Keeping this view in mind, one reviewer reviewed the remaining records and full texts. Ultimately, the selection process, displayed in Fig.  1 with the PRISMA flow diagram by Moher et al. [ 29 ], yielded 30 relevant full-text articles that met the selection criteria.

PRISMA flow diagram of the review process

Data extraction and synthesis

Data were extracted from full-text articles using a Microsoft Excel form with a pre-established list of data items with the following headings: first author and year, study location, design, sample, and relevant findings. The study location was derived from the first author’s country and the sample consisted of the number of participants included in the analysis – not all persons contacted to participate or excluded before analysis.

The extraction and synthesis of relevant findings were based on the theory of non-technical skills categories and elements [ 3 ] and the structured approach originally developed for the data analysis from the Critical Decision Method [ 30 ]. At first, reading articles served for better understanding and familiarization. Then, findings from each article were extracted and categorized according to their relevance to situation awareness and its elements (gathering information, interpreting information, anticipating future states), and to decision making and its elements (generating and considering options, selecting and implementing an option, reviewing outcome/decision). Reading articles indicated that the element of maintaining standards, originally attributed to the category of leadership [ 3 ], is an integral part of cognitive skills. For that reason, findings relevant to this element were also extracted. In the next stage, specific aspects and markers of each cognitive skill and element were identified in each article. In the end, all relevant findings from all articles were integrated. The synthesis of findings was organized linearly for clarity, however, in real emergency situations, the situation awareness phase overlaps with the decision-making phase. Furthermore, it must be noted that the synthesis depends entirely on qualitative data. In the case of articles with quantitative or other designs, only their quantitative, descriptive parts were used.

Of the 30 included research articles, the majority were qualitative in design ( n  = 17), then mixed ( n  = 5), Delphi ( n  = 5), and quantitative ( n  = 3). Their publication date ranged from 2003 to 2018. The study locations were Sweden ( n  = 8), United States ( n  = 5), Canada ( n  = 5), Slovakia ( n  = 3), United Kingdom ( n  = 2), Australia ( n  = 1), New Zealand ( n  = 1), Switzerland ( n  = 1), Norway ( n  = 1), Finland ( n  = 1), Iran ( n  = 1), and Taiwan ( n  = 1). The overview of the reviewed articles is given in Table  2 .

• Situation awareness

The importance of developing a good awareness of a situation represents a common theme of many studies. Prehospital emergency situations, which can change very fast and at any moment, frequently require the development of situation awareness, both rapidly and on-the-spot [ 53 ], while synthesizing information about one’s surroundings into a big picture/model of the situation [ 34 , 43 , 44 , 47 , 50 , 54 ]. Reay et al. [ 47 ] highlights constructing a malleable/flexible model, determined to be continuously revised and adapted to a changing situation [ 59 ]. The synthesis combines information from focused assessments that are here separated, yet in EMS professionals’ minds, they tend to overlap. The main assessment is focused on child or adult patients [ 42 ], and their various medical conditions and problems [ 31 , 33 , 37 , 39 , 40 , 41 , 47 , 48 , 49 , 50 , 51 , 53 , 57 , 58 , 59 ]. However, patients should not be taken only through the prism of medical issues, as they are individual human beings with different characteristics coming into play. Therefore, it is appropriate to assess them holistically, including their psycho-socio-economic-cultural background [ 33 , 37 , 39 , 40 , 41 , 48 , 49 , 53 , 55 , 57 , 58 ]. In this process, EMS crew members should not neglect information from patients’ significant others [ 39 , 48 , 49 , 55 ]. They can be valuable sources of information to manage the emergency situation to a satisfying conclusion. It also emerged that it was crucial for those in a high-risk EMS profession to assess the environment and the safety of patients, bystanders, and personnel on scene and in the ambulance [ 31 , 33 , 34 , 38 , 40 , 41 , 47 , 48 , 55 , 57 ]. This means assessing clues and significant objects in the environment that can give a notion of what happens and to assess potential risks and threats.

Gathering information

During gathering information before arriving on the scene, it is emphasized to pay full attention to the initial information from the emergency dispatch center [ 35 ]. This can provide initial pertinent information to construct a malleable model of the call. As EMS crew members approach and enter the scene, looking for clues related to the patient’s situation in the environment can add information to the model [ 47 ]. It is also important to observe the scene [ 54 ] and note (state) any environmental hazards to the self and the patient [ 38 ]. On the scene, the necessity is to focus and concentrate [ 43 ] – what an expert can do quickly and directly to the problem at hand [ 60 ]. Usually, gathering information centers on history taking and physical examination of the patient [ 42 ], which should be conducted systematically [ 54 , 57 ], promptly [ 41 , 47 , 48 ], effectively, thoroughly, appropriately to a given situation [ 54 ], and via perception and active/careful listening to information provided from the dialog with the patient [ 35 , 36 , 59 ]. Although the patient is a key information source, the information provided from bystanders’ behavior and communication [ 37 ] is irreplaceable, especially when the patient is unconscious or unable to talk. However, the reliability of such information may not always be accurate. Other relevant markers of gathering information are discriminating between relevant and irrelevant data, avoiding tunnel vision [ 54 ], summarizing gathered information after some intervals [ 35 ], and verifying information to increase reliability [ 34 , 44 ], e.g., checking verbally provided information by examination [ 35 ]. Furthermore, expertise research stresses the positive function of switching attention more between patients when more than one patient is involved [ 51 ] and spending more time looking at task-relevant areas of an accident [ 46 ]. Since emergency situations can change any minute, monitoring [ 31 ] or conducting a frequent scan of the environment [ 44 ] is crucial as a marker of good information gathering.

Interpreting information

Based on the collected information, EMS crew members made interpretations that are part of their mental model of the call. Although making good interpretations of patient‘s medical conditions is considered to be one of the required attributes [ 42 , 57 ], it is critical to evaluate findings while discriminating between relevant and irrelevant data, avoid premature closure [ 54 ], rely less on the initial diagnostic hypothesis [ 51 ], and verify it by generating and exploring a wider variety of hypothetical diagnosis – differential diagnosis [ 33 , 36 , 51 , 54 ]. Studies highlight being open to a variety of causes for the patient’s clinical representation (to accept the general and not to have to arrive at a specific diagnosis) [ 60 ], the ability to absorb, process, and combine a variety of information and information sources simultaneously [ 35 , 47 , 60 ], and making quick, sound judgments [ 60 ]. When an element of incongruent information appears, the necessity is to reconcile information [ 34 ], or to look for consistency among various information sources and to question inconsistent variables [ 47 ]. More noticeable markers of good interpreting information are responding to changes in the patient’s state, verbalizing observed trends and their meaning to other team members, increasing frequency of monitoring in response to patient condition [ 44 ], and interacting with team members that enable to correct potential misunderstanding [ 35 ].

Anticipating future states

Good situation awareness calls for anticipating what might happen: being aware of the probable scene trajectory [ 31 , 43 , 54 , 55 , 59 ] and acting anticipatively [ 51 , 60 ], which is necessary before and after arriving on the scene. In this regard, some kind of open-mindedness [ 43 ], or avoiding being governed by pre-made assumptions and prejudices, whilst at the same time expecting the known (usually the worst scenario) and the unexpected [ 39 , 52 , 58 ], seems substantial. Wireklint Sundström and Dahlberg [ 59 ] label this as being prepared for the unprepared, while Suserud et al. [ 52 ] calls it being prepared but not committed to any particular courses of action. Examples of positive behaviors related to anticipating future states are: keeping ahead of the situation with appropriate intervention, setting and communicating intervention thresholds, or continually preparing for the next phase of the mission [ 44 ].

• Decision making

Included research articles mention making decisions/actions based on situation awareness, both rapidly [ 52 , 59 , 60 ] and systematically [ 59 ]. These decisions are primarily about medical treatment and management [ 40 , 41 , 44 , 47 ], using various medical equipment, devices, and drugs, and occurring mostly with high density during the on-scene treatment phase of an emergency call [ 41 ]. Moreover, there are decisions made about the management of labor and delivery [ 41 ], nursing care and support [ 39 , 40 , 48 , 53 , 57 , 58 ], deterioration prevention [ 48 ], extrication and transport [ 41 , 44 , 47 ], and safety-related decisions focused on preventing and mitigating risks of all persons involved [ 33 , 40 , 47 , 48 , 50 , 57 ].

Generating and considering options

The next phase after understanding the nature of the situation and the patient’s problem is called generating and considering options. The research found that experts recognize not only a suitable option or what needs to be done, but also when and where it needs to happen, using subtleties in interpersonal communication [ 32 ]. It may concern a decision about what treatment to initiate, and when and where to initiate it [ 47 ]. Furthermore, the studies revealed several important markers such as recognizing and considering multiple options to solve the problem [ 43 , 60 ], considering risks and benefits [ 54 ] of different treatment and transport options, weighing up factors with respect to the patient’s condition, assessing time criticality associated with possible options [ 44 ], and recognizing contraindications/reasons to withhold therapy [ 41 ]. More observable are markers such as seeking medical advice initiating treatment [ 47 ], seeking input on various transport-related issues with all relevant parties [ 44 ], and objectively evaluating and discussing clinical and other relevant considerations with team members [ 44 , 56 ] to arrive at a suitable course of action [ 51 ]. These communication interactions occur more frequently in non-routine situations since courses of actions are already known in routine situations [ 49 , 60 ].

Selecting and implementing an option

Selecting and implementing an option can be found in several articles that discuss the importance of selecting a safe, effective, situation-specific, appropriately prioritized and timed management plan and/or decision strategy [ 33 , 34 , 47 , 54 , 56 ]. The research highlights that experts can decide and act at the right time and place [ 32 ] based on incomplete information as emergency situations often require [ 43 , 60 ]. Overall, they provide care on an advanced level and prepare their patients better for specialized care in the emergency department [ 51 ]. Some identified positive markers of this decision making element are to state the decision to approach a patient (or not) depending on the assessment of the scene [ 38 ], request assistance from other authorities to ensure safety [ 48 ], establish a safe zone [ 31 ], to state other final decisions based on the discussed options, and to agree on these final decisions [ 38 ].

Reviewing outcome/decision

Another critical step in good decision making is to see how the situation has changed or if a decision was effective and led to desired results. In this sense, studies emphasize making more patient assessments, continuous assessments/reassessments of the patient, or reviewing the entire situation [ 33 , 38 , 47 , 51 , 59 ]. In particular, it is desirable when expectations are violated [ 37 , 47 , 54 ], after implementing a treatment plan [ 41 ], if the decision was to wait, after key stages of the transport or regularly [ 44 ]. Such reassessment informs EMS crew members about the patient’s evolving condition and other (new) emerging information. This should be accompanied by making a list of options [ 44 ] and flexible changes in the course of action when needed [ 41 , 60 ]. When certain implemented options are not working, it is good to stop current intervention, state alternative approach/intervention, and begin to use a more appropriate course of action [ 38 ]. Some cases even require the ability to modify or create new courses of action [ 43 ] – a hallmark of expertise [ 32 ].

Maintaining standards

Included studies suggest an interconnection of maintaining standards with cognitive skills. Standards represent official structured methods of responding to emergency situations. They can be national, regional, and local guidelines, protocols and policies [ 42 , 57 ], such as diagnostic guidelines [ 36 , 48 ], treatment guidelines [ 40 ], advance directives [ 45 ], specific safety policies [ 33 , 44 ], but also ethical principles and law [ 33 , 42 , 50 , 55 , 57 ]. These standards can guide situation awareness and decision-making processes. For instance, diagnostic guidelines may assist in gathering and interpreting information, and treatment guidelines and ethical principles help in making proper final treatment decisions. The authors mention the necessity of adherence to standards [ 42 , 57 ], or at least knowing them [ 40 ] to consider and follow them when appropriate [ 33 , 42 , 44 , 50 , 55 , 57 ]. At an EMS crew’s competition, following diagnostic guidelines was found to be a key in the success and may eliminate the risk of selection bias [ 35 , 36 ]. However, it must be said that the competition underlines primarily guideline-based performance. According to Wyatt [ 60 ], as opposed to novices, experienced paramedics tend to rely less on guidelines and do not follow them uncritically and word for word. Instead, they interpret guidelines and situations through their prism of experience. Besides, trusting certain guidelines may have fatal consequences, so EMS crew members must develop personal skills that transcendent the ability simply to follow guidelines [ 45 ].

In this literature review, key articles relevant to EMS crew members’ situation awareness and decision making were synthetized. The results demonstrate an increase in the study of these skills in EMS crew members in recent years when compared to the first-ever non-technical skills review [ 4 ], which covered seven papers and brought only brief descriptions without any details regarding aspects and behavioral markers of cognitive skills. The interest in the reviewed topic is shown in articles targeting partial questions regarding cognitive skills, or articles trying to encompass all relevant non-technical skills or competencies essential for EMS crew members.

Markers of cognitive skills

Many articles discuss specific aspects relevant to the cognitive skills of EMS crew members, such as the need to holistically assess a wide range of cues and information, to make various health- and safety-related decisions, and to take EMS standards into account. However, only three articles developed rating tools containing behavioral markers of cognitive skills, such as specific acts and verbalizations, that could be considered as examples of good behavior. One focused solely upon air ambulance clinicians [ 44 ], one was developed for remote/rural settings prehospital care providers [ 38 ], and one mixed technical and non-technical categories into a rating scale of paramedic clinical competence with low observability of markers [ 54 ]. More articles described required competencies [ 33 , 50 , 57 ], attributes [ 42 , 43 ], knowledge [ 40 ], and important decisions [ 41 ] or important aspects of cognitive work in the EMS setting [ 47 , 59 ]. They primarily do not show behavioral markers, but essential aspects that should be reflected in performance. On the contrary, expertise research is rare according to the low number of included articles in the review, which resulted in the description of some characteristics of expert EMS professionals based on observations and performance ratings [ 35 , 36 , 46 , 51 ]. In this way, such obtained characteristics are similar to non-technical, behavioral rating systems. A study also proved the observability of a paramedic’s expert performance during cardiopulmonary resuscitation, which was recognized based on the entire pattern of his behavior, the smoothness with which he works, and that it seems that he knows what he was doing [ 13 ]. This form of expertise represents accumulated experience and not following the rules usually taught to student paramedics. When it comes to the nature of the situation examined, only two articles are concerned with highly non-routine, mass-casualty situations [ 43 , 50 ]. This alarmingly low incidence conflicts with high threats to patient safety, and the high importance of cognitive skills in such situations. The remainder of the articles points to the prevalence of examining situations with one or a few patients.

As suggested, even though each included article constitutes a piece in the jigsaw puzzle of aspects and markers of non-technical cognitive skills in EMS crews, there is still a need for research to fill in many blank spaces. Research questions should be asked to elicit positive behavior and expertise characteristics, as well as negative behavior, cognitive errors, and biases, and it should be particularly focused on situation awareness and decision making in routine and non-routine emergency situations. Such an approach can give a richer and deeper understanding of EMS crew members’ cognition in its entirety and complexity.

Interconnection of cognitive and other skills

The relationships between cognitive skills and other skills were also revealed. At first, a link between situation awareness and decision making occurred implicitly or explicitly across many articles. One can say, situation awareness is fundamental since its quality directly affects the quality of decision making [ 15 ]. Second, maintaining standards commonly classified as the element of leadership [ 3 ] or task management [ 9 ] emerged as entering the situation awareness and decision-making processes, in which various forms of standards – such as guidelines or protocols – are followed or considered [ 36 , 47 ]. Therefore, this element was included as an integral element of cognitive skills, just as in a crisis resource management rating scale, incorporating ABC protocol into the problem-solving skills category [ 61 ]. Third, the third level of situation awareness [ 12 ], projection, or anticipating future states seems to be very close to planning and preparing, as outlined in some papers [ 52 , 59 ]. In this regard, Klein et al. [ 62 ] place the third level of situation awareness into a relationship with anticipatory thinking as a process of preparing for future events and distinguishes it from simply predicting what might happen. Fourth, there was an association of cognitive skills with some components of team leadership and membership [ 34 , 56 ]. Although the cognitive skills of leaders, as represented in the vast majority of articles, are more complex and demanding, sometimes other team members must switch their responsibilities with the leader’s role as a result of team working. It means that all team members must develop the same cognitive skills, which is in line with team cognition markers that Salas et al. [ 63 ] united for all team members. Fifth, the findings suggested the necessity of good communication skills, used to gather information about the patient either through a dialog with the patient [ 35 ] or with other key informants [ 37 , 47 ]. Communication interactions also help crew members to share and discuss information and considerations to arrive at a good understanding of the situation and decisions [ 44 , 60 ]. At last, history taking and physical examination conducted for the determination of a diagnosis [ 54 ], as rather medical skills, appeared in articles without specific information about how to do it from a purely medical point of view. However, they imply the significance of detailed patient assessment for situation awareness and decision making; hence, they were used in the review. These relationships are unsurprising, since non-technical skills are known to be close to one another and to medical and technical skills as well [ 18 , 19 ]. Unfortunately, precise descriptions of their mutual relations, influences and overlaps are rather scarce, representing another area that requires examination. An inspiration on the road to fill this research gap can be the visualization framework of macrocognitive functions, showing how they are interrelated and dynamically interacting [ 64 ].

Limitations

To make the research method and selection process rigorous, there was an exhaustive study of existing literature on the topic of cognitive skills and systematic reviews and the inclusion of more full texts to assess their eligibility, all to ensure any important paper has not been left out. The objectivity was promoted by the use of one independent rater for reviewing 30% of records and full texts, and the quality indicator of included articles applied already in database searches was the inclusion of peer-reviewed articles. However, these points may be viewed as a potential weakness of this literature review. A more critical approach would possibly bring slightly different findings. Further, the limitation is the exclusion of non-English articles, book chapters, and gray literature, which could add more relevant information. Strict selection criteria that restricted the capture of too specific aspects and all human, situational, and organizational factors that influence performance limits the results, yet the review did not have such an aim. If necessary, these issues could be inferred from the results gained here or addressed in future studies and reviews. It is also likely that some findings from related medical specialties are directly or after some adaptations applicable in EMS crew members; they were not included to keep the review as clear cut as possible. Orientation toward various EMS crew members (e.g., paramedics, emergency medical technicians, ambulance physicians, or ambulance nurses) can seem to be a misleading step. Nevertheless, to put them together was intentional because non-technical cognitive skills as general skills should apply essentially to all who work in the role of prehospital emergency care providers. Naturally, they usually need different specific medical and technical skills sets, depending on the prehospital setting (rural or urban) and health problem; this study is not about reviewing these skills. However, differences in the required level of training, skill sets and mandated interventions between EMS organizations in different countries can limit the generalizability and transferability of findings. That is why being prudent in the utilization of findings is recommended for researchers and practitioners.

To sum up, this review synthesized the body of literature on important aspects and behavioral markers of two non-technical cognitive skills of situation awareness and decision making in professionals who work in EMS crews throughout different countries. The results revealed an increased research interest in the issue of cognitive skills, several specifics relevant to the prehospital emergency setting, and the interconnection of cognitive skills with other skills categories. Most importantly, they indicate the need to examine cognitive skills further, since findings from included articles either had a limited number of observable markers or, overall, they were not comprehensive for EMS crew members. The research should be also conducted to develop a tool for assessing and training non-technical cognitive skills, which can consequently lead to the improvement of quality and safety in prehospital emergency care.

Availability of data and materials

All data generated and analyzed during this study are included in this review article. All articles included in this review article are available in relevant journals and proceedings.

Abbreviations

Emergency Medical Services

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

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Acknowledgements

I would like to thank my colleague Jitka Gurňáková for her help with the selection process. My gratitude also goes to reviewers Rein Ketelaars and Veronica Lindström for their constructive comments on the early version of this review article. This work was supported by the Scientific Grant Agency of the Ministry of Education, Science, Research and Sport of the Slovak Republic and the Slovak Academy of Sciences under Grant No. VEGA 2/0070/18.

This work was supported by the Scientific Grant Agency of the Ministry of Education, Science, Research and Sport of the Slovak Republic and the Slovak Academy of Sciences under Grant No. VEGA 2/0070/18. The agency did not participate in the design of the literature review, collection, synthesis, interpretation of data and writing the manuscript.

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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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Nursing Department, Universitat Rovira i Virgili (URV), Av/ Catalunya, 35 43002, Tarragona, Spain

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

Faculty of Medicine and Health science, Nursing Department, University Internacional of Catalonia (UIC), Barcelona, Spain

Mireia Llauradó-Serra

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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The study was approved by the clinical committee at the reference hospital in Tarragona (Spain), Hospital Universitari Joan XXIII (5/02–2017), before initiation of this study. The participants were informed, in accordance with the Declaration of Helsinki (World Medical Association, 2013), that their participation was voluntary and that they could withdraw their participation at any time without any negative consequences or risk. The participants were also informed both orally and in writing about the aim of the study before they gave their consent to participate.

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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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Disaster management and the critical thinking skills of local emergency managers: correlations with age, gender, education, and years in occupation

Affiliation.

• 1 Department of Homeland Security, United States. [email protected]
• PMID: 23067348
• DOI: 10.1111/j.1467-7717.2012.01291.x

Emergency managers must be able to think critically in order to identify and anticipate situations, solve problems, make judgements and decisions effectively and efficiently, and assume and manage risk. Heretofore, a critical thinking skills assessment of local emergency managers had yet to be conducted that tested for correlations among age, gender, education, and years in occupation. An exploratory descriptive research design, using the Watson-Glaser Critical Thinking Appraisal-Short Form (WGCTA-S), was employed to determine the extent to which a sample of 54 local emergency managers demonstrated the critical thinking skills associated with the ability to assume and manage risk as compared to the critical thinking scores of a group of 4,790 peer-level managers drawn from an archival WGCTA-S database. This exploratory design suggests that the local emergency managers, surveyed in this study, had lower WGCTA-S critical thinking scores than their equivalents in the archival database with the exception of those in the high education and high experience group.

© 2013 The Author(s). Journal compilation © Overseas Development Institute, 2013.

• Age Factors
• Educational Status
• Emergencies*
• Employment / statistics & numerical data
• Middle Aged
• Risk Management / organization & administration*
• Sex Factors
• State Government*
• Time Factors

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

What are you struggling with in nursing school?

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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.

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Critical Thinking Skills in Emergency Management Essay

During a crisis or an emergency, different departments and organizations are involved in the response process. However, the interdepartmental and inter-organizational aspect implies that people will have varied decision-making capabilities and approaches. Unfortunately, the involved parties cannot access each other’s information systems, and thus, one individual, department, or organization is not aware of the others’ needs. Therefore, critical thinking plays a crucial role in the success of the response to emergencies.

The first step towards improving critical thinking in emergency management involves building situation awareness of the crisis. This aspect requires all the involved parties to understand the nature of the crisis that they are handling. In addition, all participants should be aware of all the other involved parties in managing the situation together with their interests. The next step involves enhancing communication within and amongst teams (Schraagen and van de Ven 314).

Efficient communication allows individuals and teams to share crucial information concerning the crisis at hand. In essence, communication forms the backbone of any efficient critical thinking in emergency management. Efficient communication allows the involved parties to avoid tunnel vision and biased information within and amongst teams.

In addition, with proper communication, individuals get precise details of the communicated information, which enhances decision-making during an emergency. Moreover, individuals can enhance critical thinking by seeing beyond the decisions arrived at in a bid to establish the motive underlining some actions coupled with the repercussions, both long-term and short term, of the same.

Being proactive and thus anticipating circumstances, which leads to the formulation and assessment of alternative solutions, also fosters critical thinking (“Georgetown University” par. 4). Finally, knowing the rules, regulations, laws, and ethics that govern emergency response improves one’s capability to make critical decisions during such times.

Works Cited

Georgetown University: Executive Master of Professional Studies in Emergency and Disaster Management 2014 .

Schraagen, Maarten, and Josine van de Ven. “Improving decision making in crisis response through critical thinking support.” Journal of Cognitive Engineering and Decision Making 2.4 (2008): 311-327. Print.

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