In my view, modern healthcare is plagued by two critical issues: the excessive reverence of protocols at the expense of sound clinical judgment and a looming educational crisis. Algorithms, protocols, and checklists guide many aspects of care, especially in the care of patients suffering from stroke or other cerebrovascular diseases. These protocols provide consistency, promote safety, and reflect evidence-based best practices. Yet, in the neuro ICU, where subtle changes may signal catastrophic deterioration, there remains no substitute for expert clinical judgment. Nurses and advanced practice providers (APPs) are often the first to detect these early warning signs, which are not always captured by a score, guideline, or imaging study. In these moments, when the ‘algorithm’ isn’t enough, clinical judgment becomes the most vital tool we possess. At the same time, neurocritical care professionals have known for some time how difficult it is to recruit and retain qualified professionals in this important specialty.

Pattern Recognition and the Subtle Decline

While protocols reduce variation and improve care standardization, over-reliance on them can lead to delays in care or poor outcomes. Protocols are written with the average patient in mind, but neuro ICU patients are often anything but average. Additionally, much of the critical care literature is difficult to generalize to the neurocritically ill patient population. For example, ventilator weaning protocols may not fully capture the likelihood of tolerating extubation in a patient with a posterior fossa hemorrhage and brainstem compression who is otherwise doing well on minimal settings. In such cases, providers must adapt care to the specific clinical scenario and not the other way around.

With time, APPs and bedside nurses develop a form of expert intuition with experience - the recognition that a patient “doesn’t look right,” even when vital signs are stable and the Glasgow Coma Scale or NIHSS are unchanged. For example, a patient with a subarachnoid hemorrhage may show signs of delirium like a delay in response time, agitation, confusion, or changes in mood or affect—any of which could be potential indicators of cerebral edema, delayed cerebral ischemia, vasospasm, or hydrocephalus. These findings may not trigger any algorithmic intervention (such as the order to “notify provider for a GCS change ≥ 2” at this author’s hospital), but timely recognition and advocacy by the nurse or APP can prompt re-imaging, adjustment of monitoring, or escalation to neurosurgical or neurointerventional consultation.

Case Reflection: When Checklists Fall Short

A middle-aged patient recovering from decompressive craniectomy for malignant edema following intracranial hemorrhage was initially ‘stable’—awake and following simple commands, though with left hemiparesis, neglect, and homonymous hemianopia. However, overnight, the bedside nurse noted slight restlessness and difficulty engaging the patient during routine neurologic assessment. As per the NIHSS, the exam was still technically within baseline. Nonetheless, the nurse escalated the concern to the APP, who ordered a repeat CT head. Head CT revealed subtle hydrocephalus and evolving perihematomal cerebral edema, leading to the initiation of hyperosmolar therapy. Clinical vigilance, not protocol adherence, led to a much-needed escalation in care.

Teaching the Gray Areas

It seems that year after year it becomes more and more difficult to recruit and retain professionals who can move past the earlier stages of clinical judgment development and thus be able to think beyond what our protocols require. In neurocritical care, the line between a stable and decompensating patient is often thin, and not always evident on paper. In my time as an educator and seasoned professional, I have often lamented that new graduate professionals of all ‘disciplinary stripes’—nurses, physicians, advanced practice providers, and others—are often linear thinkers. ‘If this, then that’ goes the thinking. Indeed, Patricia Benner, a prominent nursing theorist identified in her Novice to Expert theory identified this as the prevailing pattern of thought in the early stages of a nurse’s development (Benner, 1982), which I would argue applies to other disciplines as well.

A few recent events inspired me to renew my calls for hospital leaders, such as neuro ICU medical directors, lead/supervising APPs, nurse managers, and hospital nurse educators to do more to properly orient new nurses and APPs to the neuro ICU. Hopefully, heeding my call will remedy the problems described at the outset. First, a colleague recently recounted the challenge of a new graduate physician assistant (PA) who has had difficulty transitioning from student PA to practicing professional. From failing to recognize the importance of a patient’s subtle neurologic change to difficulty applying the knowledge gained from the NCS Advanced Practice Provide Orientation Course© to real bedside clinical practice, their orientation has been marred with challenges. And in my own hospital, there have been several instances of new graduate nurses (or nurses new to the neuro ICU) requiring multiple extensions to their orientation or even transfer to a lower acuity unit due to difficulties meeting the defined outcomes of their orientation program.

In each of these cases, I have asked myself rhetorically, ‘are we serving these professionals the best we possibly could?’ I have previously written, both here in Currents and elsewhere, about the need for pre-licensure programs to step up their game and improve educational outcomes to prepare clinicians who are more ‘practice ready.’ Keeping this in mind, I can only wonder if we are not doing enough to identify knowledge and practice gaps and taking the right steps to remediate. I heard seasoned clinicians say many times to a more junior colleague, “you need to read more.” Perhaps, though, the issue is more translational rather than purely knowledge based. Clinical judgment is not innate. For nurses and APPs new to neurocritical care, structured orientation programs with increasing clinical exposure, real-time feedback, and case-based learning are essential. Exposure to uncertainty is a must. For this reason, perhaps we should be using more simulation-based techniques to onboard these new graduate professionals.

It is true that not every hospital has the same level of resources. However, it is important to recognize that simulation is not limited to state-of-the-art manikins. In fact, high-fidelity simulation is not dependent on the modality, nor is it exclusive to a specific kind of patient simulator; modality and fidelity are distinct concepts in healthcare simulation (Carey & Rossler, 2023). Case studies (Englund, 2020), standardized patients (Chen et al., 2017), and role play (Kim, 2018) have long been a mainstay in health professions education and can be effective teaching-learning practices if carefully designed and implemented. Video recording of these sessions with guided review and debriefing can be instrumental in remediating knowledge and practice gaps (Strand et al., 2017).

Simulation-based training, especially high-fidelity, can immerse new clinicians in these gray areas. Scenarios involving delayed herniation, occult seizures, or subtle clinical changes challenge clinicians to interpret nuanced findings, synthesize multiple data points, and act decisively when protocols are silent. The orientation of new staff should include more simulated scenarios to teach new graduates, both RN and APP alike, the nuances of each scenario and how to manage them. Learning to properly assess, diagnose, and manage these high stakes scenarios in the low-risk simulation environment can be the difference between life and death later on.

To address the dual crises of overreliance on protocols and inadequate preparation of new graduates, simulation must be embedded within every orientation program— not just as an afterthought or optional enrichment, but as a foundational component of training. It should focus on common yet high stakes neurocritical care scenarios that demand real-time interpretation of nuance, not rote adherence to flowcharts.

Simulation should help new RNs and APPs not just memorize what to do, but also learn how to think. Sometimes the best outcomes begin with a hunch. And in the neuro ICU, that can make the difference between irreversible decline and meaningful recovery.

A Call to Action

Beyond this, I would urge the Neurocritical Care Society to partner with hospital systems to develop and pilot a neurocritical care orientation program embedding these and other principles. Such an initiative could represent the foundation of an impactful research study while also potentially leading to better clinical outcomes.