AACN News—December 2003—Opinions

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Vol. 20, No. 12, DECEMBER 2003

President's Note

Rising Above: New Questions, New Opportunities
Is It Only a Dream?

Dorrie Fontaine, RN, DNSc, FAAN
AACN President

I'm dreaming of a critical care unit where...

� Patients are never in pain for more than a minute.
� Everyone on the healthcare team "plays well together."
� Visitors come and go freely depending on what patients need.
� Nurses can't wait to go to work because staffing is just right.
� Patients can sleep when they need to.
� Time-honored traditions and new challenges have the right mix.
� Nurses in their 70s are working without fear of back injuries.
� The drugs and equipment nurses need for their patients are always there.
� The length of nurses' shifts balances the unit's needs and their own.
� Family members are welcome at rounds when they're in the unit.
� Music therapy, hand and foot massages and patients' pets visiting are the norm.
� Documentation takes less time than caring for patients and their families.
� Nurses can speak up about patient care with physicians and other colleagues without feeling intimidated.

Quite the list. And, some might say, quite the optimist.

For the past few months, you've joined me in rising above and analyzing some of critical care nursing's thorniest problems. The holiday season reminds me that rising above is also a strategy of optimism, though perhaps not as optimistic as my dream list.

I would love to work in such a dream unit and know quite a few nurse colleagues who would sign right up for its dream team. Others probably didn't make it past the visitors-on-the-loose idea. That's OK. I added it to keep us on our toes even if it does strike a tender nerve for so many of us.

Communication Is Key
We really should start at the bottom of the list, because effective communication is arguably the foundation for success in everything we do. Without it, our dream unit doesn't stand a chance.

In so much of our lives-and almost universally in critical care-ineffective communication points out how inadequately we handle crucial conversations, the title of a enlightening little book recommended to me by our past president Denise Thornby. (Patterson K, et al. Crucial Conversations: Tools for talking when stakes are high. New York: McGraw-Hill; 2002)

Crucial Conversations can help us learn to dialogue with genuine intention that gets positive results. A crucial conversation involves two or more people when the stakes are high, opinions vary and emotions run strong. The authors suggest that humans are "hard wired"incorrectly. Just when we need clear thinking and cool answers the most, our stress response sends blood away from our brain to other organs. So, when our emotions kick in, and they invariably do during a crucial conversation, we're doomed to failure unless we master new skills.

The authors promise this: Master your crucial conversations, and you'll jump-start your career, strengthen your relationships and improve your health. The chapter titles are catchy, "Start With Heart,"Make It Safe,"Explore Others' Paths,"Move to Action�- and the book delivers tools to use every day. My personal favorite is "Yeah, but�"with all our worst nightmare co-workers described in living color. The book even has a convenient Web site-www.crucialconversations.com-where you can take a quiz to learn about your style under stress and get feedback to hone your skills.

Face the Conversation
The book builds on examples of crucial conversations from everyday life, suggesting practical ways to manage them. Typically, when we face the need for such a conversation, we dive in and handle it poorly-or avoid it altogether. But there's a third option that only very skilled individuals can seem to pull off: Face the conversation and handle it well. Here's how it works.

Choose a recent crucial conversation at work. (Isn't it sad that we often have so many to pick from?) Maybe it's this conversation, which I've heard nearly everywhere I traveled this fall:

Nurse questions rationale behind a new treatment order. Physician responds with a withering glance or worse, a sarcastic comment. Nurse quickly learns to not question this particular physician-but one day the order is dangerously wrong and a major error is made.

A crucial conversation was long overdue, wouldn't you say? A response based on Crucial Conversations might be something like this:

Before the physician runs off to check x-rays after rounds, the nurse guides the physician into an empty room and starts the conversation by saying, "You know I really believe we both want what is best for patients on this unit and to do this I need to feel free to ask questions. I know it can work better for us if we listen to each other and cite the data to support our position on treatment options.�

Dare to Dream
I continue to enjoy the privilege of snooping around critical care units across the country. Without fail, fellow nurses tell me about their patients. About their joys, their challenges and their disappointments. Communication issues come up in each category-but especially the latter two. Faith Roberts, a rehabilitation expert and popular NTI speaker, reminds us that every 10 seconds a baby boomer turns 50. With three or four generations in today's healthcare workforce, it's no wonder communication gets so complicated.

As for me, I'll continue entertaining the dream of a critical care unit where nurses consistently speak up about patient care with physicians and with other colleagues without feeling intimidated. Getting better at my crucial conversation skills is one way I can make this happen-optimistically rising to my dream, one conversation at a time.


Message Applicable Outside Workplace
After reading the "President's Note"("Rising Above: New Questions, New Opportunities: Embrace the Art of Possibility,"AACN News, August 2003), I bought the Art of Possibility. What an incredible book. It really has had an impact on me. I am definitely applying it in my workplace and sharing the message with others with much

I also used the principles when I competed recently with my dog, Aja, in the North American Dog Agility Championships in Calgary. The principles conveyed in this book were so helpful, even in this setting, and really made a difference in how we ran and how successful we were. We really ran as a team, coming in eighth overall in our division.
Patricia Moloney-Harmon,
Baltimore, Md.

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