Better teaching in the intensive care unit: navigating a complex, multi-disciplinary learning environment

Abstract

Background

The intensive care unit (ICU) is a demanding, high‑pressure environment that requires specially trained staff, yet newly trained healthcare professionals often feel inadequately prepared to manage the urgent and complex situations often encountered. The unique nature of the ICU and the diverse backgrounds and experiences of the ICU team create both challenges and opportunities for teaching and learning. Many strategies have been proposed to enhance teaching in the ICU but are often underused. In this perspective, we highlight five approaches that may be used to improve ICU education.

Teaching strategies

(1) Use the Dunning-Kruger diagram to assess the gap between perceived competence and actual learner performance so that teaching can be targeted appropriately according to each individual’s place on the curve. (2) Use various training methods to limit cognitive overload, such as using short, focused teaching encounters or a flipped classroom model. (3) Use experiential learning to take learners out of their comfort zone, being careful not to push them into the panic zone. (4) Use a safe and inclusive learning environment that encourages all team members to contribute actively. (5) Use a competency-based approach to teaching rather than a time-based approach, recognizing differences in individual progress through task performance and providing a more personalized teaching program.

Conclusion

Quality teaching is crucial to ensure that ICU professionals are well prepared to deliver safe, evidence-based patient care in the demanding ICU setting. Using some of the approaches outlined herein to integrate cognitive and technical aspects of patient management in a learner-centered manner will facilitate effective teaching in this complex learning environment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-026-05845-w.

Introduction

The intensive care unit (ICU) is a high-pressure environment where the need for rapid decision-making and intervention, high stress levels, and the diverse backgrounds and experiences of the team members, present unique challenges for effective teaching. Many newly-trained physicians feel inadequately prepared to manage patients with emergency conditions, and surveys have demonstrated poor performance in some areas, notably clinical skills [1]. This lack of preparation can be attributed to limited exposure to a sufficient variety of acutely ill patients during undergraduate training or clerkship rotations [2, 3]. For novice nurses too, the ICU constitutes a challenging learning environment, where they often feel overwhelmed and inadequately supported [4, 5].

Training curricula must offer more hands-on experiences of acute patient care [6]. However, teaching and assessing skill application in the ICU is difficult because safety concerns preclude direct involvement of novice learners in patient management [7]. Moreover, duty hour restrictions, shift work, and night float rotations reduce clinical exposure time and opportunities for practical, bedside teaching. The ICU hosts a wide range of learners from different professions, whose diverse educational backgrounds and training levels, as well as variable exposure to rarer high acuity, low occurrence (HALO) procedures, may also complicate skills teaching [1, 4].

Learning theories in critical care teaching emphasize the need for learner-centered and reflective teaching methods to optimize the development of clinical reasoning skills and competency in managing acutely ill patients [8]. For optimal learning, the learner should be exposed simultaneously to both cognitive and technical aspects of care in an integrated manner, rather than compartmentalizing knowledge, skills, and attitudes into separate curricula as was previously common practice [9]. There must also be a focus on helping learners to translate evidence-based medicine to bedside practice, applying current knowledge to patient management [10, 11].

Importantly, ICU education is a longitudinal, continuous exercise, from under- to post-graduate levels and beyond. It should be guided by principles that support lifelong learning. Although teaching methods have evolved, lectures are still the most widely used approach in large ICUs [12, 13]. Bedside teaching does occur but is often informal and unstructured. ICU teachers need to recognize and actively leverage their central role in driving individual and cross-team teaching. As ICU patient care is inherently team-based, ICU teaching should involve all team members, including nurses, physiotherapists, pharmacists, and others, as well as physicians. Each healthcare professional should act as learner or teacher according to their expertise in a particular setting or situation [14, 15]. Indeed, ICU nurses show positive attitudes towards teaching ICU residents [16], and nurse leadership in education should be promoted [17].

Here, we highlight and discuss some key principles of ICU education (Fig. 1 and Table S1 in Additional File 1) that are often underexploited. Although discussed separately, many of these approaches overlap, and not all will apply in all situations or be possible in all units. Different strategies should be combined in the most appropriate manner to optimize the teaching and learning experience to produce knowledgeable, highly competent ICU professionals.

Fig. 1.

Five learning principles that should be used to shape teaching in the ICU

Use the Dunning-Kruger diagram

Feeling competent and being competent are two different things. Perceived preparedness for a task is not always correlated with learner performance, a gap described as the Dunning-Kruger effect, which is highly relevant in medical education (Fig. 2) [18]. Learners lacking skills tend to overestimate their competence, while skilled learners often assess their abilities more accurately [19]. Importantly, miscalibrated self-assessment is a regular feature of professional growth across many disciplines, such as aviation and business management, and represents a typical stage in developing expertise. Heightened confidence in novice learners can be beneficial, serving as a source of motivation and willingness to get involved in patient care. However, it may be less helpful during care planning and management, where underestimation of uncertainty in a complex clinical situation could compromise patient care [20, 21]. Indeed, someone who overestimates their grasp of a topic may not ask for help, mistakenly thinking they know what to do. This effect can exacerbate knowledge gaps and encourage performance errors, with a direct impact on patient care. Teachers should therefore aim to harness the motivating aspects of early confidence while also fostering a reflective approach to learner performance to support independent, safe, effective practice [21].

Fig. 2.

The Dunning-Kruger curve in education

Ideally, a learner’s position on the Dunning-Kruger curve should be assessed regularly by the teacher by asking short, targeted questions requiring answers that enable objective calibration of the learner’s baseline knowledge or clinical experience. Recognizing where the learner is on this curve can help tailor appropriate, constructive feedback. Poorly calibrated competence can lead to cognitive bias and errors in clinical reasoning, which can result in diagnostic and management mistakes and adverse patient outcomes [22]. For example, a common problem for novice learners is tunnel vision, where they focus on a single interpretation of a clinical problem, neglecting alternatives and ignoring the complex interplay present in many critically ill patients. This cognitive bias can exacerbate their misplaced overconfidence. Another example involves highly digitalized learning environments, where learners increasingly use artificial intelligence (AI) as a self-teaching tool during clinical practice. Access to AI-generated information may increase confidence without a corresponding gain in evidence-based competence. Such tools should not replace the development of informed, evidence-based knowledge, as this may transform learners into passive consumers of information rather than autonomous, active, and reflective practitioners. Teachers should guide learners to critically appraise the accuracy and relevance of all the content they use in clinical decision-making [23, 24].

To limit cognitive bias and promote well-calibrated competence, learners should be encouraged to verbalize their decision-making process, so that teachers can validate or correct their reasoning in real time. Importantly, this process should be bidirectional: teachers can act as role models by “thinking aloud” during patient management. By explaining their actions, they can help learners avoid bias in clinical reasoning when faced with similar clinical situations [25–27]. In this way, learners not only identify their knowledge gaps but also build confidence that aligns with their increasing skills.

Limit cognitive overload

Working memory has a limited capacity when dealing with novel information, including for professional tasks [28]. Learning is impaired when the complexity of the professional task exceeds the learner’s prior background (intrinsic overload), or when irrelevant information overwhelms the learner’s attention (extraneous overload) [29]. In clinical practice, physician−nurse interactions can provide a clear illustration of these mechanisms, with repeated questioning, information sharing, and multiple orders contributing to both intrinsic and extraneous cognitive overload for both professions.

Cognitive overload may also occur in teaching contexts and awareness of this potential is particularly important when teaching in the ICU, an environment where complex clinical situations can lead to considerable stress for trainees and qualified professionals. Learning can be said to occur across three different zones (Fig. 3): comfort, a familiar, low-stress environment where learners engage in routine tasks with minimal effort and little learning or growth actually takes place; learning or stretch, where learning is challenging but manageable; and panic, where cognitive overload and overwhelming stress impair learning. Teachers should encourage learners to move beyond their comfort zone, without pushing them into their “panic zone” [30, 31]. Importantly, the boundaries between each zone will vary among individual learners and may differ within the same learner for different learning experiences.

Fig. 3.

The three learning zones in education

To limit overload and help learners stay within their optimal learning zone, they should be exposed to professional tasks in different areas of intensive care gradually, allowing them to progress in a manner consistent with their level of training [32]. For example, teaching and assessing leadership behavior while managing an unstable polytrauma patient may be appropriate for expert learners, but for junior students this may be better taught when managing a stable patient.

Teaching strategies to limit overload can be applied even when time is limited by employing short, focused teaching encounters. One example is the “one-minute preceptor” model, which is based on five micro steps: get a commitment, probe for supporting evidence, teach general rules, reinforce what was done right, and correct mistakes [33]. The first step involves finding out what the learner thinks is wrong with the patient, making them commit to a diagnosis or treatment plan. This can help the teacher assess the learner’s needs or knowledge gaps and identify potential teaching opportunities. The next step is to try to elucidate how the learner reached that decision by encouraging them to verbalize and justify their thought processes. The third step involves specific teaching to address any identified gaps in knowledge, based on general rules that can be applied to other situations [34]. Finally, the last two steps involve reinforcing what the learner has done well and indicating and correcting any mistakes and how to avoid them in the future. This teaching tool thus focuses on a specific learning objective and helps channel the learners’ attention to meaningful content over a short period of time, reducing the risk of cognitive overload.

Another approach that can help limit cognitive overload is the flipped classroom model. Core concepts and essential foundational knowledge are studied by the learner at their own pace before class, using videos, gamification, virtual reality, quizzes, and learning platforms such as Moodle, an online tool for creating and delivering online courses. This is then followed by in-class teaching with interactive activities based largely on problem-solving [35–37]. This approach offers a flexible strategy that spreads learning by enabling learners to prepare in advance, thus optimizing classroom time with the teacher and limiting risks of overload during the active teaching sessions [38, 39].

Challenge learners slightly beyond their comfort zone with experiential learning

Experiential learning is the process of gaining knowledge and skills through meaningful hands-on experience and thoughtful reflection on those experiences [30, 40]. Kolb described a four-step, cyclical process [41]: Concrete experience, when the learner engages in a real-life experience; Reflective observation, when the learner reviews and reflects on the experience; Abstract conceptualization, when the reflections are synthesized into abstract concepts, enabling learners to draw conclusions; and Active experimentation, when these concepts are applied and tested in new situations. Teachers should design teaching experiences that actively engage learners in a real-life, contextually rich, and relevant context enabling them to apply theoretical knowledge, develop practical skills, and engage in critical reflection. However, this should be done in a fashion that challenges without overwhelming.

Simulation sessions integrate these principles of experiential learning and are well established as an effective method of teaching procedural skills [42–45] as well as soft skills, such as teamwork, situational awareness, and communication [46]. The choice of high- or low-fidelity simulation should be considered carefully by the teacher to optimize learning goals. There is some evidence that low-fidelity simulation (using simple manikins) is effective for procedural training, such as bronchoscopy or catheterization, while high-fidelity simulation (using advanced patient simulators) allows deep exploration of critical thinking skills and assessment of team dynamics [47, 48]. Simulation can be used to teach competency in management of complex conditions at the bedside [47, 49, 50], for example, an unstable patient after insertion of a left ventricular assist device (LVAD). This approach takes learners from all the healthcare professions beyond isolated knowledge or technical drills, and helps integrate knowledge, skills, and behavior within a single experiential-based scenario. Finally, experiential learning may be particularly well suited to HALO events, as it is highly immersive and can place learners in near-real, authentic care situations without compromising patient safety. However, full-day simulation may not be optimal given the low frequency of these events. Short, focused simulation sessions, such as those embedded in a flipped classroom model or delivered through virtual simulation, may provide broader and more feasible access to these critical scenarios [51].

In addition, lengthy simulation sessions are not always feasible in ICU teaching due to time constraints and the limited availability of simulation equipment or facilitators in some units. Just-in-time training methods, such as the “stop and go” method, can be integrated into simulation-based teaching, giving instructors the flexibility to adjust the length of the debrief if time is limited [52]. In this approach, instructors can pause the scenario and correct individual or team errors in real-time, preventing consolidation of incorrect skills. For example, during a simulated cardiac arrest scenario, the instructor can pause the scenario to correct poor chest compression practice that has gone unnoticed by the team leader.

Just-in-time training can also be used in clinical environments, with two main approaches. The first is “over-the-shoulder” guidance, in which real-time coaching or guidance is provided by the teacher during task performance. This strategy provides immediate correction and reinforcement while encouraging reflection, anticipation, and situational awareness [53]. For example, while a learner presents their care plan for the patient, the teacher can challenge them by asking: “How do you see today’s plan changing if the patient does not improve by tomorrow?”. During a procedural task, “over-the-shoulder” guidance enables direct correction of inadequate movements or technique. A second key form of just-in-time training consists of making a brief revision of the topic or task immediately before a procedure. As an example, before performing a bronchoscopy on a hemodynamically unstable patient, the learner might watch a video reviewing the anatomy of the bronchial tree. This preparation improves procedural fluency and performance [54–57]. It can also decrease cognitive overload, which can occur when a learner must both perform the procedure and manage the patient’s hemodynamics.

Foster a safe and inclusive learning environment that integrates the learner within the team

Teachers can promote a psychologically safe learning environment by encouraging open communication and mutual respect [58–61]. Embracing conflict constructively enables professionals to speak up without fear [62] and improves team functioning and performance [63]. Differences in background, culture, training, and experience among team members should not be viewed as obstacles, but recognized as valuable opportunities to enrich team learning [64].

In this setting, enthusiasm during rounds, clear explanations of decision-making reasoning, empathy for patients and families, and respect for colleagues are hallmarks of teachers that are valued by learners [65]. Rounds represent the highest level of collaboration and promote shared decision-making and time-efficient individual and team-based teaching [14, 66–68]. An optimal learning climate during rounds is grounded in psychological safety, ensuring that each professional can openly share their expertise and opinion and engage in interprofessional teaching [69, 70]. All team members should feel comfortable contributing actively to discussions. The multiprofessional and multilevel nature of the ICU bedside team in terms of degree of training and expertise offers a rich opportunity to learn from diverse perspectives, while also presenting challenges for effective teaching. Engaging the entire team may be difficult during rounds, as teaching must avoid being either too general or overly targeted to a single learner group or profession. Several multilevel teaching techniques (e.g., broadening, targeting, students-as-teachers) may help address this challenge during rounds [71, 72]. For example, teachers can adapt questions to different levels of expertise by first discussing a simplified bedside clinical situation with novice learners, then broadening the discussion for more advanced learners by asking “what if” questions that increase case complexity (e.g., adding comorbidities or clinical instability). Teachers may also invite learners to teach peers or members of other professions, reinforcing shared learning. Such approaches help engage and empower each individual around patient care. The use of each team member’s expertise increases team effectiveness [73]. In a highly specialized environment, each collaborator should be valued and recognized as a potential teacher, contributing their specific expertise to team learning [74, 75]. Finally, during ICU rounds, communication is central, as communication gaps are one of the main sources of conflict and adverse events at the bedside [76–78]. Perceptions regarding the effectiveness of communication often differ between nurses and doctors, related to hierarchical factors or differences in training methods, with nurses reporting less open communication [79]. ICU teachers, as team leaders, can contribute to flattening the hierarchy by encouraging input from all team members [61, 80].

Effective communication is also central to constructive interprofessional feedback or critical event debriefing, allowing teams to learn from complex situations while ensuring the psychological safety of staff. While debriefing after simulation is a central component of teaching, debriefing after critical events in clinical practice often depends on individual willingness and initiative. Debriefing may improve team well-being and performance, yet barriers such as time constraints, hierarchical dynamics, workload, or fear of judgment may hinder its implementation. To support clinical debriefing as an effective learning tool, the ICU department should actively foster and structure a culture of debriefing adapted to its local context [81–83]. Specific debriefing tools should be used for this purpose, as they can reduce barriers to initiating debriefing and facilitate interaction between professionals [84, 85]. As an example, the use of uniform communication strategies for end-of-life family conferences can decrease anxiety and post-traumatic stress disorder after a patient’s death [86]. Other standardized communication tools, such as the TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) framework or the three Cs (Clear instructions, Citing names, and Closing the loop), may also improve communication [87–89] and, by doing so, help promote a safe, respectful, and effective learning environment.

Adopt a competency-based approach to teaching

Competency-based medical education (CBME) is an approach to education that focuses more on the outcomes of teaching than on the duration and is increasingly adopted in pre- and post-graduate health profession education [90, 91]. Within this model, in a medical curriculum setting, entrustable professional activities (EPAs) are groups of competencies that a novice doctor should be able to perform on their first day of residency or at the end of their specialty training [92]. Teachers can use entrustment scales to specify the degree of autonomy a learner can have or the amount of supervision required −from direct observation to fully independent− when performing a specific EPA [93, 94]. As a learner’s competence improves, the amount of supervision required will decrease accordingly. At the end of standard, time-based training, the ability of learners to perform different tasks will vary according to background experience, completed rotations, clinical exposure, and learning trajectory. Lack of preparedness or competence by novice doctors poses a risk for patients, with potential errors in diagnosis and management [7, 95, 96]. The CBME approach provides concrete, clear, and achievable training goals that support learner progression in tasks directly relevant to patient-centered care. Recognizing that not all learners progress at the same rate allows for a time-variable, more personalized teaching program. Successful daily application of CBME in the ICU requires active support from local faculty and program directors to ensure sustainability. These programs should help to develop summative assessments of competence, enabling learners to take clinical responsibilities aligned with their level of competence. Graduated exposure to professional tasks should be guided by competency rather than by training level alone.

Use of a CBME approach is not without challenges, requiring a rethink and reorganization of standard approaches to training. In the ICU, several frameworks have been developed to harmonize training and methods of assessing novice intensivists’ readiness for independent practice. One example is the Competency-Based Training in Europe (CoBaTrICE) program [97], which has been adopted by many European countries, and defines the “minimum standard of knowledge, skills and attitudes required for a doctor to be identified as a specialist in intensive care medicine”. The CoBaTrICE collaboration identified 102 competence statements that learners should achieve, grouped into 12 general domains: resuscitation, diagnosis, disease management, interventions, procedures, perioperative care, comfort and recovery, end-of-life care, pediatric care, transport, safety and management, and professionalism. The CoBaTrICE platform provides guidance on curriculum design, learner assessment, and adaptation to local contexts, and enables alignment of intensive care training across international settings.

Conclusion

The high-pressure ICU environment, characterized by rapidly changing patient conditions, complex and urgent decision-making, and multidisciplinary collaboration presents both significant challenges and rich opportunities for teaching. Learners’ self-confidence must be aligned with objectively assessed competence to ensure safe patient care. Teachers should serve as role models, fostering resilient, reflective, and competent healthcare teams that are adequately prepared to handle the specific demands of critical care. They must incorporate the unique expertise of each professional into the teaching experience to promote team learning. Current fixed-time, “one-size-fits all” approaches to teaching should move toward more time-flexible, competency-based education, employing some of the tools discussed herein. Techniques to optimize experiential learning should be employed and learners encouraged to leave their comfort zone while avoiding cognitive overload. Future research should focus on assessing the impact of educational interventions in ICU settings at program level using a combination of observational studies, pre- and post-intervention assessments, and simulation-based formative and summative evaluations. Effective training is essential to produce competent ICU professionals with the knowledge, skills, and attitudes to provide quality, evidence-based patient care.

Abbreviations

AI

Artificial intelligence

CBME

Competency-based medical education

EPA

Entrustable professional activity

HALO

High acuity, low occurrence

ICU

Intensive care unit

LVAD

Left ventricular assist device

Author contributions

MG drafted the manuscript. JLV edited it for critical content. Both authors read and approved the final manuscript.

Funding

No funding was received.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

JLV is Editor-in-Chief of Critical Care.