Critical Care Environment: Strategies for Success

Survival as a registered nurse in today’s critical care areas requires development of specific coping strategies to deal with the stress encountered on a daily basis. These techniques will benefit both the newest critical care nurse, as well as the seasoned veteran.

As you enter a patient’s room, stop near the doorway and do a quick visual sweep of the room.  As you conduct this primary survey, look for anything out of the ordinary. Check to be sure that all equipment is plugged in, turned on/off, and connected/disconnected, as appropriate. Look for full suction canisters, safety hazards such as blood or fluid spills, stray needles, or dangling tubes and wires that may entangle your feet.  With practice, this can be completed in only a few seconds. The time is well spent and could save precious minutes in an emergency.  It helps to get this view from the doorway because it can be a jungle in there! Sometimes it can be difficult to separate the forest from the trees.

Once this is complete and you have determined it is safe to go further, move to the bedside and begin your secondary survey.  This is where your patient assessment begins. After you have introduced yourself and announced your intentions you can begin a quick visual scan of your patient. It helps to use the same approach consistently-probably using a head to toe search pattern. Check for the obvious, like skin color, nasal cannula or oxygen apparatus in place, IV site condition, drainage tubes functioning, color of drainage fluids, chest excursion, and condensation in the ventilator circuit. In short, if it should be going in, be sure it’s going in and if it should be coming out make sure it’s coming out.  Don’t forget to look under the covers! Many things may be lurking there. You will be amazed at what you can learn about your patient and his condition by training yourself to automatically do these quick “visual exams”

As you start your shift always take a few minutes to prioritize the care for each patient. This can be done by simply making a list of the most important tasks that must be done during your shift and ranking them in order of importance. Of course your list is constantly subject to revision as the day unfolds, but keeping a simple list can help keep you organized and on track throughout the shift.  Always try to group tasks together that require assistance, such as decubitus care on a coccyx while a bath and linen change are being done.  This helps both you and your coworkers make the most of the precious time allotted for your workday.

Try to have a task completed by the time it is due. In other words if you have a very time-consuming task, like a dressing change or wound packing, that is due at 9:00 AM, start the procedure early enough to be finished at 9:00 AM. If you wait until the scheduled time to start, you will invariably run into problems; and before you know it, you are an hour late with 10:00 am meds. This rule of thumb helps you to pace the care, be done on time, and out the door at quitting time!

Let’s face it, on a typical day in the ICU you probably won’t have enough time to get everything done that needs to be done, much less the extras that you want to do.  Sometimes you can be so overwhelmed by the workload that you don’t know what to do next.  This is the time an observant coworker should offer to help! Don’t be caught saying, “Gee thanks, but I don’t know what to have you do.”  Always have a list in the back of your mind so if help comes to the rescue you can respond with, “Hey thanks a lot, would you please give Mr. Jones in Bed 7 his 10:00 am meds?”  This way, when you are up to your armpits in alligators you have a plug someone can pull, to help drain the swamp!! Delegating or asking for help in a timely manner is the key to prevent sparks from becoming forest fires.

Always trust your instincts. Go with your gut feelings. In the 1980’s television show Magnum PI, starring Tom Selleck, this idea was personified. The detective Thomas Magnum would narrate the story and frequently refer to that “little voice inside me” that would warn him of trouble.  Magnum always got into big trouble anytime he didn’t heed the “little voice inside”.

Even though you have thousands of dollars worth of equipment bombarding you with information that says everything is within normal limits, always trust that nagging, gut feeling that tells you something isn’t right.  Ask a coworker to assess your patient, discuss your concerns with a supervisor, or even give the doctor a call.  Nine times out of ten, your gut feeling will be accurate, and you can avert major problems by trusting your instincts. Many experienced nurses have averted pending disaster by trusting their instincts rather than depending solely on instrumentation. Remember: Treat people not machines!!

Calling a physician, especially in the middle of the night, can be particularly stressful.  Nevertheless, there are ways to make these situations less troublesome for everyone involved. Always take a few minutes to “concentrate your information” prior to reaching out and touching someone. Make yourself a checklist to use as an aid in gathering the information at hand, so it will be readily available. The following information should be available to you before you call the physician:

• flow sheets,
• vital signs,
• height and weight,
• allergies,
• IV fluids type and rate,
• medication lists,
• intake and output,
• net fluid balance,
• current labs and EKG’s, and
• the current physical assessment

If you do this first, it may very well prevent you from looking like an idiot and keep inpatient physicians from frustration!  If you are calling a physician who is on-call for the patient’s regular physician, be sure to have a brief history and admitting diagnosis on hand as well. Seldom do covering physicians get the kind of report that nurses do at shift change. It is reasonable to expect a covering physician to know next to nothing about your patient, or his problems. Taking these steps will prepare you to answer nearly any question or quickly find any information a physician might request.

A little planning can go a long way toward saving you hundreds of extra steps. Before you start a procedure, check the supplies available in your patient’s room, and make a list of everything you need, thus eliminating unnecessary trips to the supply cart. If you have the time at the beginning of your shift, when you do your environmental surveys, take note of items that are in short supply. Making a list and checking it twice, can save you countless steps.

It is also extremely helpful to your coworkers to leave your rooms well stocked, neat, and orderly at the end of your shift whenever possible. Be especially alert to low supplies of frequent use items like-fresh drinking water, straws, tissues, cups, tape, 4 x 4’s, washcloths, electrodes, and incontinence pads. What goes around comes around! Who knows, you may start a trend that will help everyone have needed supplies when they need them. A little consideration of others can come back to bless you. In short, get organized, be considerate of others, and use your head to save your feet.

Volumes have been written about the effects of daily stress on healthcare workers. Surviving in the high stress, high tech world of critical care nursing demands that professional healthcare workers take care of themselves.  A simple Internet search using compassion fatigue, burnout, or stress management as search terms will yield a mountain of helpful information. Here we will discuss some background information, signs and symptoms, and some general steps to take to help alleviate this all too common affliction of healthcare workers.

Dr. Charles Figley, PhD director of the Florida State University Traumatology Institute is a leader in the field of compassion fatigue and burnout. He defines compassion fatigue as “a state of tension and preoccupation with the individual or cumulative trauma of clients as manifested in one or more ways: (1) re-experiencing the traumatic events (2) avoidance/numbing of reminders of the traumatic event, and (3) persistent arousal. It is absorbing and retaining the emotional suffering of others in interaction with other experiences, past and present.”

Dr. Figley defines burnout as: “a state of extreme dissatisfaction with one’s clinical practice characterized by (1) excessive distancing from clients, (2) impaired competence, (3) low energy, (4) increased irritability with supporters, and  (5) other signs of impairment and depression resulting from individual, social, work, environmental, and society factors.” The following table summarizes the effects of these syndromes.

The onset of either syndrome is gradual and insidious. Stressors just seem to pile up with each event taking its toll, until the healthcare worker’s coping mechanisms fail. Early recognition of these symptoms helps make recovery much easier.  However, an ounce of prevention is certainly better than a pound of cure. Start early in your career and develop a care plan for your soul.  Be sure to include interventions such as a sound diet, regular exercise, adequate rest, relaxation techniques, and other measures that minister to your mind and spirit. As healthcare workers, we can easily allow ourselves to become consumed by our roles. Try to develop a technique to visualize separating yourself from your workday. As you remove your stethoscope and hang it in your locker, leave the stress, anxiety, and woes of your day hanging there with it, instead of dragging them all home. At home, they will only erode the joy of care giving and thus life in general. Remember: you are worth it!

By completing the following self-assessment tool, you can evaluate your risk and your current compassion status.

Compassion Satisfaction and Fatigue (CSF) Test

Helping others puts you in direct contact with other people’s lives. As you probably have experienced, your compassion for those you help has both positive and negative aspects. This self -test helps you estimate your compassion status: How much at risk you are of burnout and compassion fatigue and the degree of satisfaction with your helping others. Consider each of the following characteristics about you and your current situation. Write in the number that honestly reflects how frequently you experienced these characteristics in the last week. Then follow the scoring directions at the end of the self-test.

0=Never     1=Rarely      2=A Few Times     3=Somewhat Often     4=Often       5=Very Often

Items About You

1. I am happy.
2. I find my life satisfying.
3. I have beliefs that sustain me.
4. I feel estranged from others.
5. I find that I learn new things from those I care for.
6. I force myself to avoid certain thoughts or feelings that remind me of a frightening experience.
7. I find myself avoiding certain activities or situations because they remind me of a frightening experience.
8. I have gaps in my memory about frightening events.
9. I feel connected to others.
10. I feel calm.
11. I believe that I have a good balance between my work and my free time.
12. I have difficulty falling or staying asleep.
13. I have outburst of anger or irritability with little provocation
14. I am the person I always wanted to be.
15. I startle easily.
16. While working with a victim, I thought about violence against the perpetrator.
17. I am a sensitive person.
18. I have flashbacks connected to those I help.
19. I have good peer support when I need to work through a highly stressful experience.
20. I have had first-hand experience with traumatic events in my adult life.
21. I have had first-hand experience with traumatic events in my childhood.
22. I think that I need to “work through” a traumatic experience in my life.
23. I think that I need more close friends.
24. I think that there is no one to talk with about highly stressful experiences.
25. I have concluded that I work too hard for my own good.
26. Working with those I help brings me a great deal of satisfaction.
27. I feel invigorated after working with those I help.
28. I am frightened of things a person I helped has said or done to me.
29. I experience troubling dreams similar to those I help.
30. I have happy thoughts about those I help and how I could help them.
31. I have experienced intrusive thoughts of times with especially difficult people I helped.
32. I have suddenly and involuntarily recalled a frightening experience while working with a person I helped.
33. I am pre-occupied with more than one person I help.
34. I am losing sleep over a person I help's traumatic experiences.
35. I have joyful feelings about how I can help the victims I work with.
36. I think that I might have been “infected” by the traumatic stress of those I help.
37. I think that I might be positively “inoculated” by the traumatic stress of those I help.
38. I remind myself to be less concerned about the well being of those I help.
39. I have felt trapped by my work as a helper.
40. I have a sense of hopelessness associated with working with those I help.
41. I have felt “on edge” about various things and I attribute this to working with certain people I help.
42. I wish that I could avoid working with some people I help.
43. Some people I help are particularly enjoyable to work with.
44. I have been in danger working with people I help.
45. I feel that some people I help dislike me personally.
46. Items About Being a Helper and Your Helping Environment
47. I like my work as a helper.
48. I feel like I have the tools and resources that I need to do my work as a helper.
49. I have felt weak, tired, run down as a result of my work as helper.
50. I have felt depressed as a result of my work as a helper.
51. I have thoughts that I am a “success” as a helper.
52. I am unsuccessful at separating helping from personal life.
53. I enjoy my co-workers.
54. I depend on my co-workers to help me when I need it.
55. My co-workers can depend on me for help when they need it.
56. I trust my co-workers.
57. I feel little compassion toward most of my co-workers
58. I am pleased with how I am able to keep up with helping technology.
59. I feel I am working more for the money/prestige than for personal fulfillment.
60. Although I have to do paperwork that I don’t like, I still have time to work with those I help.
61. I find it difficult separating my personal life from my helper life.
62. I am pleased with how I am able to keep up with helping techniques and protocols.
63. I have a sense of worthlessness/disillusionment/resentment associated with my role as a helper.
64. I have thoughts that I am a “failure” as a helper.
65. I have thoughts that I am not succeeding at achieving my life goals.
66. I have to deal with bureaucratic, unimportant tasks in my work as a helper.
67. I plan to be a helper for a long time.

© B. Hudnall Stamm, TSRG, 1995 -2000 http://www.isu.edu/~bhstamm. This form may be freely copied as long as (a) authors are credited, (b) no changes are made, & (c) it is not sold.

Last updated 3/12/2002 11:21 PM

Suggested Reference: Stamm, B. H. & Figley, C. R. (1996). Compassion Satisfaction and Fatigue Test. Available on the World Wide Web: http://www.isu.edu/~bhstamm/tests.htm.

Scoring Instructions

Please note that research is ongoing on this scale and the following scores should be used as a guide, not confirmatory information.

1. Be certain you respond to all items.
2. Mark the items for scoring:
   1. Put an x by the following 26 items: 1-3, 5, 9-11, 14, 19, 26-27, 30, 35, 37, 43, 46-47, 50, 52-55, 57, 59, 61, 66.
   2. Put a check by the following 16 items: 17, 23-25, 41, 42, 45, 48, 49, 51, 56, 58, 60, 62-65.
   3. Circle the following 23 items: 4, 6-8, 12, 13, 15, 16, 18, 20-22, 28, 29, 31-34, 36, 38-40, 44.
3. Add the numbers you wrote next to the items for each set of items and note:
   1. Your potential for Compassion Satisfaction (x):  118 and above=extremely high potential; 100-117=high potential; 82-99=good potential; 64-81=modest potential; below 63=low potential.
   2. Your risk for Burnout (check): 36 or less=extremely low risk; 37-50=moderate risk; 51-75=high risk; 76-85=extremely high risk.
   3. Your risk for Compassion Fatigue (circle): 26 or less=extremely low risk, 27-30=low risk; 31-35=moderate risk; 36-40=high risk; 41 or more=extremely high risk.

Avoid getting tunnel vision and focusing strictly on your own assignment.  It is far too easy to be submerged in the monumental tasks before us each shift and thus lose track of what’s going on around us.  Whenever possible take note of your coworker’s plight and offer your assistance. This goes far to establish an atmosphere of teamwork and can come back to you many times over!

These eight strategies will go a long way toward helping you organize yourself and ease the transition into critical care nursing. As you practice these techniques, they will become habits that can greatly reduce the stress and frustration we often experience in the compassionate delivery of patient care. After you have surveyed the environment, set your priorities, keep your ducks in a row and delegate what you can’t do, be sure to listen to your gut, use your head to save your feet, and avoid burn out by helping your coworkers put out their forest fires before they spread to your backyard!

NOTE:  URLs are given beside references rather than linked to the document name so that they can be read from print copy. 

The Compassion Fatigue Scale has been established, presented, and published in several articles/chapters including, among others, the following:

Clemens, Lisa Ace. (1999). Secondary traumatic stress in rape crisis counselors: a descriptive study [thesis]. California State University, Fresno, M.S. thesis; Masters Abstracts 37/06: 1965.

Figley, C. R. (1998). Burnout as systemic traumatic stress: a model for helping traumatized family members. In C. R. Figley (ed.). Burnout in families: the systemic costs of caring, pp. 15-28. Boca Raton, Florida: CRC Press.

Figley, C.R. (1995). Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. New York: Brunner Mazel. http://www.opengroup.com/open/dfbooks/087/0876307594.shtml.

Figley, C.R. (1999). Compassion Fatigue. In B. H. Stamm, (Ed.) Secondary traumatic stress: Self-care issues for clinicians, researchers and educators, 2^nd Ed. Lutherville, MD: Sidran Press. http://www.sidran.org/digicart/products/stss.html.

Landry, L. P. (1999). Secondary traumatic stress disorder in the therapists from the Oklahoma City bombing [dissertation]. University of North Texas, 1999.

Rudolph, J.M, Stamm, B.H., & Stamm, H.E. (November, 1997). Compassion Fatigue: A Concern for Mental Health Policy, Providers and Administration. Poster presented at the 13th Annual Conference of the International Society for Traumatic Stress Studies, Montreal, ON, CA. http://www.isu.edu/~bhstamm/ISTSS97cf.PDF.

Salston, M. G. (2000). Secondary traumatic stress: a study exploring empathy and the exposure to the traumatic material of survivors of community violence [dissertation]. The Florida State University, 2000.

Stamm, B. H. (in press). Measuring Compassion Satisfaction as Well as Fatigue: Developmental History of the Compassion Fatigue and Satisfaction Test. In C.R. Figley (Ed.). Treating Compassion Fatigue. Philadelphia: Brunner/Mazel.

Figley, Charles R. (2000). Treating Compassion Fatigue, Philadelphia, Pa. Taylor and Francis Inc., March 2000

Skovholt, Thomas M. (2000) The Resilient Practitioner: Burnout Prevention and Self-Carefor Counselors, Therapists, Teachers, and Health Professionals, New York, NY Allyn & Bacon, Inc. December 2000

Stoter, David J. (1997) Staff Support in Health Care, Blackwell Publishers, January 1997