AACN News—September 2007—Opinions

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Vol. 24, No. 9, SEPTEMBER 2007

President’s Note

Controllable and Uncontrollable

Dave Hanson,

No matter how Herculean the effort or miraculous the result, it is impossible to squeeze more than 24 hours into a day. Believe me, I’ve tried. Yet squeezing more time into a day is what we often try to do when demands on us as acute and critical care nurses continue to escalate.

Different Kinds of Demands
Some of the demands are laughable. Consider the unquestioned expectation that nurses’ responsibilities will automatically expand to include the duties of those in other departments,Pharmacy, Patient transport, Dietary or Housekeeping, for example,when those areas are absent or short staffed. To paraphrase nurse leader Dr. Luther Christman’s wry observation, nurses seem to be the only ones in healthcare who are not solar powered. It’s assumed that we’ll be there even when it’s dark outside and everyone else has gone home.

Other demands are far more serious and compelling. Designed to ensure patient safety and bolster our reliability as nurses, those demands include reconciling medications on admission, systematically communicating patient hand-offs, authenticating verbal orders, documenting reassessment of pain intervention, nurse sensitive indicators and the critical—but flippantly named—DNUA (Do Not Use Abbreviations).

Some demands—nurse sensitive indicators, for example—are nurse driven and controlled. Others, such as Joint Commission standards, result from interprofessional expert consensus designated as a nationwide blueprint that promises enhanced patient safety and shores up the quality of care for patients and their families.

When we are challenged to reclaim our priorities, what should nurses do? Work harder? I believe you would agree that we’re already maxed out in that department. Work smarter? Absolutely. But how?

Controllable and Uncontrollable
Too many demands (i.e., priorities) require superhuman capabilities. This overabundance of demands often triggers change fatigue in which we find ourselves asking, “Will somebody please stop the world for a while so we can all catch our breath?” Working smarter means learning to differentiate between controllable and uncontrollable situations.

Making sure our priorities align with our core values of patients and families, safety and reliability, we must address only those priorities where we can have a meaningful impact. Situations that are genuinely uncontrollable cannot be changed. We either need to remove them or put them in perspective so they don’t deplete our energy and produce diminished or empty returns. However, it is important to remember that many situations are dynamic in nature and only uncontrollable for the moment, not forever. That is when we need to make informed choices and to triage priorities by taking on those that are clearly more vital, deferring less important ones. As a result, we should give ourselves permission to not feel guilty, much like we do when we make tough clinical decisions. It helps us learn to respect the value and power of our decisions.

Come Back Later
Competing priorities, lack of time, incomplete information or alliances that are either dysfunctional or have not been formed may signal the need to re-evaluate the situation later. Let’s say we face the competing priorities of communicating critical information during a patient hand-off and cleaning a patient room for a new admission because there is no housekeeper on duty. Staying to thoroughly clean the room while sending the patient with a transporter and attempting to reach the receiving nurse by phone is one possible solution.

Another option would be to accompany the patient for a face-to-face hand-off to the receiving nurse, then returning to clean the patient room so that it meets minimum acceptable standards. This may be the better alternative because it ensures patient safety and continuity of care. We can then circle back to muster allies who can help us to develop a well-thought-out way to address the ongoing, problematic issue of a lack of housekeeping staff. We cannot ignore confronting the housekeeper issue because working around it will cause us to continue wasting many hours of valuable time.

Have you been successful in handling controllable and uncontrollable situations in your own practice? How have you made informed choices? Have you developed effective ways of helping novice nurses triage and prioritize? If you will share them by writing to me at priorities@aacn.org, I can share them with others.

Letters to the Editor

Simple but Complex

When I read the President’s Note in the July issue of AACN News, I was reminded of when my 9-year-old son’s violin teacher asked him how he is able to get such great concentration on his piece. My son answered, “I focus on it like it is the most and only important thing in the world for me at that moment.”

Working in critical care, I find that focusing on my patient requires great concentration and dealing with distractions that can compromise safety. Distraction as in feeling the pressure to get my patient transferred so I can admit another from the ED, while thinking that this patient still needs his lines removed, his dressing changed, his bath and a new peripheral IV, among other things. It sounds complex and simple at the same time. Simple when I say to myself, “just think about this patient’s safety” but complex when I think of the tasks at hand.

Divina Sirokie, BSN, RN, CCRN
Ft. Lauderdale, Fla.
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