1. Hurst, Susan Marie RN, MSN CCRN, CNRN

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Last week, I was discussing project timelines with a nurse manager colleague. Our conversation ambled into a musing about some nurses' needs for adherence to unwavering timelines, especially with implementing change or novel nursing care interventions. This impatience with "getting off course," we thought, might stem from the assumption that for every problem scenario is a complementary, readily apparent solution. The dialogue subsequently became quite animated. It seemed universally expected that all one needs to do is ask, and someone, somewhere, should or will have an answer that either magically appears from the computer screen or materializes from the pages of an article. Does the following sound familiar?


* What are you doing about the staffing?


* When will the policies be done? Isn't there a committee working on that?


* Why did they change the equipment? Wasn't the old one working just fine?


* Why are we changing that practice?


* They should make a national healthcare system, don't you think?


* Why doesn't the doctor understand that we need to withdraw care? Why can't the family accept that death is near?


* Why doesn't the hospital hire more support personnel?


* What is so hard about paying us more than travelers?


* Why do "they" keep changing our management team?


* When all we hear is about money, that means nobody cares about the patients?



In the absence of definitive answers to these queries, our critical care environment operates in an atmosphere of unyielding stress. Asking questions is not the problem. It is the expectation that immediate resolution is ready and available to ameliorate the problem in question. Hence, we deliberated, what is the genesis of this professional mandate for clarity, rigor, and preciseness related to information exchange, decision making, behaving, and articulating nursing actions?


The critical care work environment strongly exemplifies this "I need an answer" culture. Monitors spew information, alarms prompt activity, screens provide data directing clinical decisions, and intravenous technology delivers fluids within a tenth of a cubic centimeter. Structured and regimented, the intensive care unit environment is constructed for safety, efficiency, detail, and, ultimately, a sense of stability for all influenced by the critical event.


As I observe nurses work, I hear the usual talk of needing to see the laboratories, understand the prognosis, and know the plan of care while shouldering the bulk of responsibility for educating the family and advocating on their behalf. So from a practical standpoint, I reflected, this "information junkie behavior" is both adaptive and required to survive in the intensive care unit setting of care. How, then, can this behavior be tempered so not to become counterproductive, maladaptive, and unrealistic in its nature?


During any time of change, priorities evolve, the future becomes uncertain, and anxieties mount. Intersecting variables confound, confuse, and alter the current understanding of reality. In response then, a good first step to answering without an answer is to acknowledge the burden of uncertainty in a manner characterized by kindness, empathy, and understanding. Acknowledge the feelings, identify the confusion, and then promote new thinking that enhances the possibility for adapting a new style to manage the current reality.


Just as patient and family angst can be evoked by uncertainty, so can the same unfold for the staff. Becoming expert in the science of change theory may be of benefit. As a first step, helping to give voice to the inner conversations and questions that fuel confusion and anxiety help the staff identify the nature of stress within their environment. In the absence of definitive information, the mind will create a menu of possibilities and errors of judgment as the environmental detail fails to be understood. Answering without an answer can be a powerful demonstration of caring while acknowledging a prominent domain of our specialty. Offering support while the confusion prevails, the environment changes, and deterioration prompts patient and family distress addresses the strife characterizing intensive care unit nurses' emotional well-being.


Each nursing specialty is marked by unique competencies required to succeed. Although exemplary critical care nurses are characterized by their attention to detail, their anticipation of future scenarios, and their central position of patient/family advocate, we must remember that it is the lack of specifics, the paucity of predictive factors to see the future, and deficiencies limiting role performance that most compromise both function and fulfillment in critical care nursing.


Susan Marie Hurst, RN, MSN, CCRN, CNRN


Critical Care Clinical Nurse Specialist Staff Nurse, Transplant Banner Good Samaritan Medical Center, 2206 N. 14th St Phoenix, AZ 85006 602-239-4490


Ms Hurst wrote the guest editorial for this issue and is a reviewer of manuscripts for DCCN