Critical Care Is Guided by Why

The American Association of Critical-Care Nurses (AACN) National Teaching Institute and Critical-Care Exposition (NTI) gathers thousands of critical-care nurses together every May. The event offers opportunities to learn, to connect, and to be inspired. Unveiling the new AACN theme, and the original artwork that illustrates it, is a highlight of NTI. AACN themes exemplify our mission, vision, and values. The NTI president’s SuperSession, which provides a transition between themes, is particularly meaningful to members. It is a time for the outgoing president to reflect about how the previous year’s theme engaged critical care nurses, and for the president-elect to unveil the AACN theme for the upcoming year. Past presidents’ themes are archived on the AACN website,¹  and those themes showcase the inspiration that anchors critical care nursing. On May 24, 2017, Christine Schulman revealed a powerful theme for her 2017–2018 presidency: “Guided by Why.”²  She reflected on the power of asking why as “a tool to accomplish our goals: as a compass, as an anchor, as a voice about things that matter,” and as a “guiding beacon for what we can—what we must—do to ensure that every patient gets the excellent care they deserve.”

“Guided by Why” can also serve as a potent frame for critical care research and evidence-based practice. Seeking to understand why provides both philosophical and scientific underpinnings for critical care. Asking why informs our theoretical and conceptual frameworks, research questions, and analyses. In quantitative research, why enables us to understand cause and effect. In qualitative research, why enables us to find meaning. Asking why encourages us to examine current practice and to propose and test new interventions and approaches.

Research investigations often begin with a search for why certain clinical outcomes occur in particular patients or under particular circumstances. For example, why are some patients at higher risk for pressure ulcers? Investigations of risk factors and protective factors associated with patients’ conditions answer early questions about differential susceptibility. Thinking about why facilitates identification of variables and helps researchers begin to hypothesize relationships among those variables. Why is the foundation for the development of theoretical and conceptual models to describe those relationships and provides the scientific premise for development and testing of novel interventions.

This issue of AJCC offers 2 examples of studies designed to inform future intervention research. Dolan and Looby³  asked what factors influenced thought processes of nurses in the surgical intensive care unit as they decided to initiate or discontinue use of physical restraints in critically ill patients. That is, why do nurses decide to use, or not to use, restraints? Better understanding of nurses’ decision-making will lead to interventions that are more likely to be successful in reducing use of physical restraints. In other instances, initial observations may not provide evidence about why, but rather may lead to additional questions. Another study of restraints in this issue⁴  used a prospective observational design, and those researchers found that the majority of critically ill patients requiring mechanical ventilation who were physically restrained in one facility did not receive any psychotropic drugs around the time of restraint; if psychotropic drugs were given, they were more likely to be given after physical restraints were applied than before restraint application. Understanding the why underlying these patterns will provide important guidance in designing effective interventions to improve practices related to restraint.

When events do not go as planned in the intensive care unit, asking why may help us to consider optimal solutions and avoid future similar events. A technique called “the 5 whys” is widely used in root-cause analysis and has made its way into health care systems safety and quality improvement.^5,6  The 5 whys technique is a component of many quality improvement programs developed for industrial settings, including Toyota Production System (TPS), Lean, and Six Sigma; it may also be applied to problem solving outside of these programs. Working backward from the event to a single root cause by asking a series of why questions, the technique is used to retroactively identify the root cause of a problem. The underlying assumption is that a solution addressing the root cause (rather than proximal causes) will be most effective in preventing a recurrence of the event. Getting to the root cause may require more or fewer than 5 why questions, but the essence of the technique is to continue asking iterative questions about why until a solution to the underlying problem is obvious. Recent critiques of the 5 whys suggest that a search for a single causal pathway, leading to a single root cause, amenable to a single solution, may be too simplistic. In the world of health care, events are likely to arise from a confluence of causes. A single problem identified as the root cause may not be the only or the most important problem to be addressed. The 5 whys approach emphasizes depth and follows a single line of reasoning to a conclusion. Especially in the complex setting of the intensive care unit, this approach may undervalue the breadth required to consider multiple, interacting, causal factors as well as contributing factors. We would argue that the concern lies not with asking why, but rather with sacrificing examination of many possible whys for the simplicity of a single (perhaps misleading) why.

Both knowledge generation (research) and application of knowledge to practice (evidence-based practice and quality improvement) are necessary to improve outcomes for critical care patients. Asking questions about why is an excellent place to start. Why can guide us to additional questions, including how and what.⁷  Let’s strive to be “guided by why”!