CHAPTER 3

 Analysis of the critical care unit as a dynamic system

 Donald E. Watson, MD

 Mosby's Comprehensive Review of Critical Care, Second Edition, Donna A. Zschoche, Ed. (1980)


The behavioral sciences have much to offer organizations seeking to optimize their productivity, stability, efficiency, effectiveness, profitability, and goal achievement. Industrial and occupational psychology and psychiatry have had an integral place in the planning and operation of organizations large and small. Through the practical application of knowledge gained from the systematic study of systems of people, these disciplines have become basic to the principles of modern management.

It is surprising, then, to realize that hospitals, as complex goal-oriented organizations, still suffer from archaic management principles that are in collision with modern expectations of employees and patients alike. If hospitals are to escape the suffocating influence of government control, the costs incurred by mismanagement must be controlled. Costs expressed as money begin with costs suffered by people, many of which are emotional costs. This chapter assesses some of those costs and suggests interventions to reduce them.

The typical health professional seeks through his or her career a mechanism for mastering individual fears; for example, the typical nurse is terrified of her own dependency needs. Yet, she chooses a profession in which other people become exquisitely dependent on her. Similarly, physicians as a group demonstrate a terror of personal illness or death, which they seek to overcome by conquering illness and death in others.

Others in the health professions and ancillary fields, ranging from hospital administrators to dietary workers to maintenance personnel, are fascinated by and attracted to the hospital as a hoped-for sanctuary against morbidity and mortality. The individual psychodynamics of all these people, mixed together in the hospital setting, becomes the large and complex social system known as hospital-based health care.

The critical care unit (CCU) is a small subsystem within the hospital. Substantial literature relating to the psychologic issues of both patients and staff of CCU's has accumulated in the past few years. Some of the literature has focused on the psychologic reactions of patients to the 24hour-a-day maelstrom of activity of the unit (for example, see Chapter 4), while others have emphasized the reactions of the staff. 1,1,3
 

 GENERAL SYSTEMS THEORY AND THERMODYNAMICS

The complexity of the CCU can be analyzed according to the principles of general systems theory. There are two main virtues in choosing that conceptual framework: (1) to better understand complex systems, and (2) to be able to predict effects. This chapter is structured in a sequence that permits a logical analysis of a CCU and then provides predictions based on those generalized observations.

The reader need not be intimidated by the language of general systems theory. The theory is simply a formalization of the commonsense notion that any system is the sum of all of its parts and that each of those parts is a system itself interacting with each of its neighbors. Accordingly, it is stated as a principle in the science of ecology that one can never change one element of a system without affecting every other element and the system as a whole.

In discussing sets of systems that are interrelated by flows of matter, energy, and information among their boundaries, it is also useful to consider the concepts provided by thermodynamics. These include the relationships of flows in and out of the system and the internal energy of the system. The concept of entropy is particularly valuable because it is a measure of the cost incurred by a system when it is in negative balance, that is, "running down."

In its simplest form thermodynamics states that (1) the total energy in the universe is constant, and (2) in performing work a system always loses some energy in the form of heat, which represents a loss of "free energy" and a gain in entropy.

It is useful to think of "psychic energy" as analogous to the free energy of thermodynamics. Experience has shown that human beings cannot be indefinitely drained mentally without suffering severe disorganization or collapse. In other words, people suffer a gain in entropy as they do psychic work. Accordingly, a principle of conservation of psychic energy can be postulated that states that the energy of the mind/brain is conserved; that is, it is neither created nor destroyed. It can, however, be transformed into intellectual activity, physical activity, "worry," acquisition of possessions, and so forth.

According to the conservation pnnciple, a person whose emotional economy is in negative balance relative to the flow of input and output across his boundary suffers a cost in internal organization; that is, his entropy increases. In psychologic terms a person whose needs are chronically unmet is steadily accumulating a propensity toward emotional disorganization or illness. Similarly, the individual's suprasystem will exhibit increased entropy if its net economy is negative.

The language in this chapter is not rigorous; it is hybridized to help bridge the gaps among theory, clinical practice, and management principles. Several definitions are useful at this point for the purpose of the analysis: level In a hierarchy of systems the degree of aggregation or complexity is called a level; for example, five levels of organization are: (1) cells, (2) an organ, (3) a person, (4) a CCU, and (5) a hospital.
 

 

 SUBSYSTEMS OF THE CCU

Each person in a CCU is a subsystem of that unit. The person, in turn, consists of his own subsystems, which include both physical and mental components. The structure and processes of'the mental subsystems are the objects of the science of psychiatry, broadly defined. Disciplines of psychiatry include the neurosciences, psychology, sociology, and economics. The body of knowledge of psychiatry is acquired by formal laboratory methods and clinical observation. Freud based his theory of character organization (called psychoanalytic theory) on a systematic study of mental processes observed by both himself and his subjects, the latter observations being called insights. Fig. 1 is a diagram summarizing the human mental (or psychic) structure and processes.

This complex system is one level lower than that of the person and two lower than that of the CCU. It is not within the scope of'this chapter to describe the CCU system in comprehensive detail. Instead, the focus is on analyzing the major problem areas. Toward that end, it is useful to describe the system from the perspective of several of its component parts, keeping in mind that the "real" world can only be described as it is perceived to be by each observer. Accordingly, not one, but four CCU's are described below: (1) the patient's CCU, (2) the nurse's CCU, (3) the physician's CCU, and (4) the administrator's CCU (in this case, the nursing director represents administration). Clearly, this list of descriptions could be extended to include the politician's, the insurance executive's, the clergyman's, the next-of-kin's, and so forth. The emphasis is on the four principals, though, because the bulk of the information exchange is carried on among those people.
 

 The patient's CCU

 The hypothetical patient in this case is a 46-year-old man who had never been sick a day in his life and had taken great pride in being a good provider for his wife and three children. He has been striken by a massive myocardial infarction and he is alive at this moment only because the ambulance crew arrived at his side in time to convert a ventricular fibrillation. When he was stricken, he was both surprised and emotionally numb; his conscious mind would not permit him to acknowledge how near death he was. During the excitement of his cardiac arrest and subsequent defibrfflation, he became aware for the first time that his life would end; at some time in the future he would cease to exist.

While being transported by the ambulance to the hospital, the patient began to develop a deep sense of affection for the attendants who were caring for him. Even though their demeanor was to remain detached from him as a person and was even at times frivolous, the patient felt a deep sense of trust for them that could only be explained by his state of enforced dependency. Although he was not consciously aware of it, the affection he felt for the attendants was the same feeling he had felt toward his mother when, as an infant, he had enjoyed her total attention, protection, and nurturance.

By the time the patient arrived at the hospital and was wheeled by gurney into the CCU, other feelings began to emerge: While he could still perceive the hospital as a sanctuary that was filled with fantasied mother figures who would take care of him, he also felt a terror that was only partially softened by the effects of the morphine he received. The terror he felt came from deeply buried memories from his childhhood when he was first struggling to become independent. Unable to verbalize his fear, he was flooded by uncertainty; "What if they don't really love me?" "What if they mutilate me while I am helpless?" "Can they be trusted to know what they are doing?" "What will they do with me while they have me in their control in my helpless, dependent state?" "Will I ever be able to depend on my own body again?"

By this time, the patient has already established in his mind a set of responses and behaviors that he expects from the nursing staff. These expectations are highly individual, based on his own early life experiences and brought to the foreground by the regressive experience of acute illness. It is important to be aware that he expects both positive and negative reactions on the part of the nurse; above all, he expects that he will be totally within the power of these angels/devils that will be ministering to him.

Within the first few hours after being admitted to the CCU, the patient goes through many substantial emotional ordeals. Facing the fact of'his mortality for the first time is devastating. The imminent threat of losing everything precious to him is almost overwhelming. Within the span of' a few minutes, the patient becomes aware of' what is truly important to him in his life. f f e discovers that even though most of his energies until his illness struck had been spent with his career, the predominant preoccupation of loss is not with his work at all. Instead, it is the fact that he might not be able to see his children grow to adulthood, and that he might not be able to grow old and enjoy his retirement with his wife. Suddently, his entire set of priorities is turned around. He condemns himself for putting off pleasures and he regrets not having made opportunities to be closer to his family. If'he appears to be uncooperative to the nurse who is trying to start an IV or attach electrodes to him, it is because his agenda of priorities is considerably different from hers at that moment.

Later, as the patient proceeds with grieving for his lost delusion of'immortality, he may express his rage at the CCU-his immediate environment. He may become bitterly intolerant of the constantly lighted room or of the incessantly noisy equipment. Or, in an attempt to regain his sense of'maste and control, he may become obsessively preoccupied with the complex array of' devices surrounding him. Above all, he will be anxious constantly because of his totally novel experience with illness and the exotica of the CCU. Unlike the nurse and the physician, he cannot regard the CCU as commonplace.
 

 The nurse's CCU

 The hypothetical nurse, 28 years of age, has been part of the elite critical care team for a little over a year. She had decided to become a critical care nurse soon after her first exposure to the CCU while in nursing school. She had been excited by the potential for developing a special competence in a highly technical area of nursing in which her own expertise would sometimes exceed that of the physicians who hospitalize their patients in the unit. She had paid her dues to reach the position she was in now; she had worked nights and evenings all over the hospital and had even "floated" for several months.

Prior to entering nursing school the nurse had worked as a waitress for 2 years to support her husband while he tried out college. The divorce happened about 6 months after the baby was born and about a year after her husband dropped out of college to "find himself" Even though she knew it would be difficult, she entered nurses training with a sense of determination and strength. She knew she could be a good nurse because she had always taken care of people. She had decided on a career in nursing when she was 13 years old. As the oldest of six children, she functioned as a mother to her younger siblings while her own mother worked long hours to support the family.

She was an ideal critical care nurse: She was bright, dedicated, idealistic, and quietly reliable. She had earned the confidence of her supervisors by frequently working 9- and 10-hour shifts in order to assure that all the work got done. She was proud of the fact that her errors had always been small and had never led to major compl,ica-' tions for her patients. She was also proud of,the fact that her superiors and her peers alike often turned to her for support during times of crisis.

Despite the high degree of achievement in her career, though, the nurse was also vaguely dissatisfied. She was tired. She was also feeling guilty for neglecting her son. Her routine recently had been to pick him up from the day-care center after her shift, prepare a meal for both of them, get him ready for bed, and retire herself soon after he did. It seemed that in the last few months she had to sleep longer and longer in order to have the energy to return to work the next morning. Secretly, she yearned for an "ideal" man; one she could depend on and who would take care of her. She despaired of ever finding such a man, though, because she knew she would never be able to relinquish her cherished independence. Still, she displayed a bumper sticker that told the world to "Love a Nurse prn."

On this particular day, the nurse was more "tired" than usual. She had developed a special fondness for one of her patients, a man in his late 50's, who was recovering nicely from a myocardial infarct. Over the weeks he had been her patient, they came to know each other fairly well. Developing a relationship with the patient was unusual for her but in this case she permitted herself to make an exception. Perhaps it was because she was vulnerable in her loneliness and perhaps it was because he vaguely reminded her of her father. He was different from her father though in one important respect: He did not abandon her. Also, unlike most of her patients, he seemed to be nurturing and interested in her as a person and was therefore able to provide her with a sense of acceptance and personal worth she had not experienced before. But on this day, 4 days prior to his expected discharge, he suddenly died. She had blindly and instinctively called a code and had personally led the resuscitation team. Completely able to deny her loss at the time, she functioned like a precision-tuned machine. It was to no avail; the hopelessly scarred heart would not start again. So this man, too, left her.

The nurse's peers and even her head nurse tried to give her support. They said they knew how she must feel. They asked if there was anything they could do. They even touched her and stroked her back as she sat holding her head in her hands after the nursing ritual of death had been completed. But she could accept no support from them because she was too isolated in her grief. The nurse fleetingly wondered if she was experiencing depression but quickly dismissed it from her mind; depression was for the weak and the self-pitying. She would have no part of it. Still, she was grateful that only 1 hour was left on her shift and she was left with only one patient to care for next to the empty bed recently occupied by her special patient. It was at that time that the gurney rolled in with a new patient: A 46-year-old, well-respected businessman who had had a massive infarct.

The nurse felt heat at the back of her neck and almost simultaneously a weakness in her legs and arms. Unconsciously, she was enraged at the intrusion of this stranger who was going to be demanding her care but at the same time she became "paralyzed" because her conscience admonished her that rage is forbidden. So, much to the amazement of her colleagues and supervisor, she efficiently and quicoy picked up the rhythm of attending to the new admission. It was as if she had no feelings whatsoever.

As she approached the man to start connecting him to the various monitoring devices of the unit, he flailed at her as if he were taking a swing at her. This had happened many times to her before, but she had always shrugged it off as an unexplained phenomenon. This time, though, she took it personally. She shouted at the man to hold his goddamned arms still or he would pull out the IV's.

Instantly, she felt totally contemptuous of him in his helpless and dependent state. He didn't seem to be affected by her outburst though; he only looked at her in passing as if her presence made only the tiniest impression on the periphery of his consciousness. She quickly regained her composure and silently thanked the morphine, giving it credit for keeping the patient's attention away from her transient loss of control. It did not occur to her that the man's preoccupation with things more important to him than her behavior had accounted for his casual dismissal of her actions.

This rare instance of an outward expression of stress did not go unnoticed by the nurse's conscience. Unconscious mechanisms came into play that would serve to keep her in line thereafter; her rigid, critical, and tyrannical conscience (acquired program) would make sure this new patient would receive the best care she could possibly deliver. She became overly zealous in monitoring the man's vital signs and even went out of her way to ask him if he were comfortable. Even though she had been aware of a sense of guilt after her outburst, she did not consciously connect the guilt with the fact that she stayed 2 hours overtime that day, ostensibly to make sure the PM nurse was adequately informed about taking over the care of the new patient.

By the time she got home that evening, she was snapping at her son and even briefly permitted herself to wish that she did not have him as a dependent. She went to bed exhausted that night but sleep did not come for many hours. Troubling thoughts tumbled through her head but always too quickly for her to be able to grasp them or to understand where they came from. She didn't even think about the death of her special patient. Perhaps she had "forgotten."
 

 The physician's CCU

 The physician, 46 years of age, had had a relatively easy day. He had started his hospital rounds at 7:30 in the morning and even had time'to wolf down a sandwich at 1:00 before returning to his office to see patients. He had been on call that day for emergency admissions, but the emergency room physician had not called him all day. He was relaxed, bantering back and forth with a long-time patient who was grateful to him for having diagnosed her mysterious illness and for treating it. When the call came from the emergency room physician, there was no doubt about the diagnosis or the course of treatment for the man who just came through the door at the hospital. The clinical signs were unmistakable and the patient had been sent directly to the CCU.

The physician hastily excused himself'from his waiting patients as he rushed through his waiting room by waving and explaining "Emergency!" He knew he did not have to run and that other physicians in the community would let the CCU nurses manage the case with only telephone consultations. But he had his own internal ideals that drove him. He rushed to the hospital and went straight to the patient's bedside. He could see at a glance, but did not consciously note it, that the patient was about his size and build and was about the same age. Checking the monitors quickly, his practiced eye flagged the danger signs immediately. All he could say was "Damn!"

It was safer to look at the nurse. He was pleased to find that it was his favorite nurse and he knew she would relieve him of a considerable burden because ot' her competence and dedication. He took the time to notice that she looked different this time. Her face lacked the mobility he was accustomed to, her eyes looked a little sad, and she seemed pale. He thought she could take care of herself, though, so he dismissed it and headed for the patient's chart to write orders.

As he glanced over the cursory workup recorded by the emergency room physician, the physician wondered if'he had heard the patient's name before. He seemed to recall being introduced to a man with that name at the handball court a few weeks previously. However, he dismissed that, because there was no way of' connecting the energetic, robust, and healthy man at the handball court with the pitiful, helpless mass of tissues he had just seen.

When he saw that the patient's age was the same as his own, the physician could only feel anger at the unfairness of the specter of'death attending a man so young. A memory flitted across his mind about the dizzy spells he had suffered on occasion within the last year. He pushed that out of' his mind, though, with a simple denial. Then he chuckled wryly to himself when he became aware of' his reliance on his superstition: "I'm a physician, and physicians don't get sick." Introspection made him nervous, so the physician quickly finished his chart work and returned to the nurse at his patient's bedside. For a moment, he saw her as different from a nurse, almost as a human being. His practiced clinical eye told him that she was in distress and he wished that he could do something to help her.

Unfortunately, he needed her to be a nurse at this time. Therefore he only told her that he was really grateful that she was on duty with his patient and that she was the best nurse he had ever known. Hoping that his words would be enough to relieve whatever distress she bad, he turned quickly to return to his office and to the patients who were waiting for him.
 

 The administrator's (nursing director's) CCU

 The nursing director commanded the respect (or fear) of everyone at the hospital. The only exception to this was the nursing director herself. In 55 years she had come to acquire a great deal of power and was able to either coerce, persuade, or manipulate practically anyone at the hospital into doing her will.

It had not always been so. Before she was 2 years old, the nursing director had experienced more chaos and upheaval in her life than most people do in a lifetime. Her father, whom she does not remember, was the cause of'all that. As a child, she had tried to imagine what her father had been like, but since her mother never mention ed him, she had little information to go on. She knew that she had had at least 14 different homes during that 24-month period, including one relatively long stay of'3 months with an aunt. Whether or not her father uprooted his family and moved them so frenetically was because of restlessness, eluding capture, avoiding persecution (either real or imagined), or just mental instability was never known to her. Nevertheless, the experience left her with a deep-felt belief'that she would never find security.

Despite her deep-seated sense of insecurity, the nursing director frequently and vigorously denied feeling insecure, proclaiming to all who would hear that she was able to master any challenge. Thus she compensated for her sense of inadequacy by grandiosity; what others saw as rigidity and strength was actually her defense against fragility. Unconsciously, she was riding a vicious circle: Because she felt insecure and powerless, she garnered all the power and control she could. Rather than relieving her sense of weakness, though, the added responsibility only made her feel more inadequate. To cope with that, she reached for more power, and so on.

The nursing director was herself aware of subtle changes that had taken place in her attitude about herself in the past decade. After having tried and rejected marriage while she was still in her 20's, she had embarked on a career that would combine her professional skills with her dependency instincts. She headed without hesitation toward administration and after an early series of triumphs that were rewarded with promotions and accolades, she developed a satisfying sense of invincibility about her capacity for mastering the world in general. While in her 30's, she stepped from position to position in several hospitals, each representing a major advancement over the previous ones. She decided that she was capable of spending her entire working career moving thus from challenge to challenge, expecting frequent and intense exhilaration from practicing her skills. Something had happened to her somewhere along the line, though, but she did not know what it was. She did know that she had been in her present position for 12 years and she no longer had the inner resources to welcome new challenges.

The only person the nursing director answered to in the entire hospital was the administrator. Fortunately for her, both she and the administrator knew that she was her own boss. The administrator knew that unlike the old generation, the young nurses considered that they owned their own lives and were not chattel of the hospital. Accordingly, he knew that he could not dictate policy without permission from the nursing director. She in turn added to the power she held within the hospital by extending her influence to other hospitals in the area and to the major nursing organizations as well. Although the nurses who feared her wrath considered her to be a tyrant, her own self-perception was that she, in her wisdom, would make more "right" decisions than her subordinate nurses would if they exercised any autonomy.

The nursing director rarely ventured into the clinical areas of'the hospital. When she did, it was to assess for herself' the accuracy of' the reports given her by her immediate subordinates, the supervisors. Some of the physicians in the hospital were faintly bemused by the nursing director's posture: It was ironic that despite her reign of terror in which she held absolute control, her internal feeling of insecurity manifested itself by paranoia. They speculated sometimes among themselves about why the hospital kept her, a relic from the sweat shop days of hospital management. But despite her flaws, there was one thing no one could deny: The nursing director ran a tight, quiet ship and the administrator appreciated that.

On this day, the nursing director visited the CCU at about the same time the patient was wheeled in. She strode briskly over to the desk to check his admission sheet. Noting quickly the upper middle-class neighborhood where the patient lived, the excellent insurance coverage, and the apparent adequacy of documentation of his hospitalization so far, she quickly computed the expected revenue if the patient survived 3 weeks, and felt satisfied that the risk of malpractice litigation would be low.

Then she turned her attention to the nursing personnel on the unit and quickly assessed each of them according to her highly personalized agenda. The head nurse was giving her full attention to the nursing director, disregarding all of the activity on the unit. The nursing director nodded an acknowledgment to the head nurse while reassuring herself that the head nurse was obsequious enough and would cause her no trouble. After glancing over and quickjy discounting the significance of the other members of the nursing staff, her eyes fell on the nurse attending the new patient. While she was reflecting that he didn't like the nurse because she was well repected by the doctors and most of the rest of the ursing staff, she was suddenly surprised to witness an emotional outburst by the nurse at the bedside. Smugly, the nursing director concluded that documentation of shouting at a patient in that nurse's personnel file would quench any threatening ambitions she might have, at least for the time being.

The nursing director turned and swept back to her office, already rehearsing the report she would give the administrator: that all was well in the hospital under her direction and the only problem she had observed would be dealt with appropriately.
 

PSYCHODYNAMICS OF THE FOUR PEOPLE (SUBSYSTEMS) OF THE CCU

 The vignettes of the individuals related in the preceding are of hypothetical individuals; in fact, they are composites of real individuals and as such they are "real" people. In the average CCU three of these four people are statistically represented fairly accurately; the majority of physicians and nurses and many nursing directors have personalities very similar to these composites. Patients, of course, have no such uniformity of character. They are placed at the scene for reasons far more diverse than those of career choice. As a result, the analysis following is illustrative of only one set of interactions, in which one variable (the patient) is subject to considerable uncertainty. Nevertheless, the analysis is valid for this particular set of variables at this particular point in time. Indeed, the nature of any dynamic system is the same. For that reason, the methodology must be applied continuously; today's solutions for today's problems will probably not be appropriate for tomor-row's problems.

The style of the preceding presentation is deliberately dramatic. It emphasizes the fact that the emotional activity in the CCU is intense and information about that emotional activity ("affect") is freely exchanged even though it is rarely acknowledged consciously. The impact on the four individuals involved in the exchanges of emotional information is largely destructive. The analysis below of the four parallel subsystems within the CCU is intended to help clarify the processes of'those destructive interactions, to assess their impact, and to suggest remedies.

The four human subsystems of the CCU, together with their own internal organization of emotional information, each comprise a separate but interdependent economy. The CCU is designed to provide a highly sophisticated system of support for the patient's physical economy. The body's healing processes are carefully and continuously monitored so that interventions in the form of input of matter, energy, and information, properly timed, across the patient's system boundaries can reduce the amount of the system's disorganization (iflness). In other words, in order to reduce the entropy of the system, the economy of the patient's body requires that external management temporarily supplant his normal internal control mechanisms.
 

 The patient's psychodynamics

 As illustrated in the case vignette, the patient's physiologic and anatomic processes are not the only ones affected by his illness. His psychologic steady state has also been severely disrupted. During the same minutes and hours that the CCU team is concentrating on the reorganization of his body, the patient is desperately trying to reconstitute a steady state emotional position.

While his long-standing psychologic mechanisms have been abruptly disorganized, the input of organizing information from an external monitor and support systems for his psyche would be helpful. The device best suited for this task is another human being, but that person's own economy must permit the outflow of information without seriously upsetting his or her own steady state. In the preceding vignettes it is obvious that the nurse was unable to provide the external organizing information required by the patient because she was herself in a state of high emotional entropy.
 

 The nurse's psychodynamics

 The nurse in the preceding instance offers an example of a long-term process of increasing emotional entropy. Because of her genetic programming, her emotional economy requires contact with human beings. Her natural requirements are for a sense of security, and intimacy with a mate. Unfortunately for her, though, she has been programmed by life experiences to resist having those needs met; that is, she has "learned" that it is not safe to come to depend on someone. As a result, her emotional economy at the moment is in negative balance-she is "giving" more than she is "receiving" emotionally useful information.

Because of her unstable economy, the nurse instinctively "knew" that her survival Was at stake. That, in turn, caused her to experience rage when one more demand was made on her in the form of a new patient. In addition, she suffered negative feelings on the death of her special patient because that event triggered a grieving response that was unable to become operative.

The grieving process in human beings is a normal healing process triggered by a loss. Grieving permits a reorganization of psychologic variables in order to reduce the entropy gain caused by the loss. In her case, she had never completed the process of reorganizing her psyche after she had been abandoned by her father. Therefore she had entered a state of "pathologic grieving," which left her permanently disorganized and therefore unable to (1) comfortably form dependent attachments to others and (2) satisfactorily complete the process of grieving for this most recent loss. A human system cannot forever remain in a state of negative balance emotionally. Eventually, the system will collapse; the nurse will most likely suffer a state of severe depression eventually.
 

 The physician's psychodynamics

 The physician in the vignette demonstrates an economy similar to that of the nurse's. It is in negative balance by virtue of a strong drive to be helpful to others. Organizing information early in his life experience had the result of programming him to respond to the world as if his needs for emotional sustenance could be met only if he "earned" it by being useful to others. Accordingly, his fear of becoming dependent on someone else was based on the belief that to do so would mean annihilation. Even so, his genetically determined psychic organization, like that of the nurse, requires that he receive emotional nourishinent in order to maintain a steady state ("happiness").

The primary psychologic mechanism of the physician for dealing with the conflict between his innate and "learned" organization is denial. Despite his education and experience he refused to acknowledge the possibility that he too could become ill. The evidence that his body had its limits came from the dizzy spells; the evidence that his emotional economy had limits was that he retreated from giving the nurse the kind of emotional support she needed.
 

 The nursing director's psychodynamics

 The nursing director in the vignette reveals still another style of trying to maintain a steady state emotional economy. In her case, information obtained through early life experiences had programmed her to respond to the world as if she would never be permitted the security of settling down in a continuous comfortable environment. Still, her genetic programming made such a dependable, structured existence necessary for her to maintain a stable state. Early in her career, she had tried to accommodate her belief that stability was impossible and was successful for a time in the discovery that not only could she deliberately move around a lot but that she could master and thereby enjoy the challenges of moving as well. While doing that, she also developed a mechanism ot'drawing emotional energy from others by coercion; she became obsessed with gaining power over others and thereby "learned" the illusion that parasitic behavior is a satisfactory substitute for obtaining emotional support that is freely given by others.

As the nursing director aged, the effects of her earlier coping mechanisms came back to haunt her. She had made many enemies and was aware that there were those who wanted her annihilated. Accordingly she became extremely suspicious of others and she continually escalated her reign of terror. She had never been a "giving" person like the majority of her nurse colleagues, but by now her insensitivity to the needs of others-patients, physicians, and subordinates alike-had reached its maximum levels. She was nongiving as a matter of principle; she needed all the security, wealth, and power she could acquire in order to try to satiate the need for tranquility that had been unmet since she was bom.
 

 EMOTIONAL ECONOMIES OF THE FOUR PEOPLE

 There are no units by which to measure the variables of emotional transactions between people. Instead, quantification is best achieved by using units of time. Consider the analogy of a battery; the economy of a battery can be assessed in terms of the total or amount of charge stored (coulombs) minus the discharge rate (coulombs per second or amperes) plus the recharging rate (coulombs per second) over a given period of time. Such an assessme .pt would require constant monitoring of inflow and outflow and would be awkward for most applications. Instead, it is simpler to rate the battery according to how long it would take to drain (units of time) at a given discharge rate. Similarly, the quantification of a person's "emotional balance" can be made by determining how long a person can give to others before collapsing, depleted. Obviously, the rate at which the person receives the replenishment will contribute to the results.

The individual emotional economies of each of the principals can now be examined in detail. The four individuals with their economies are combined in a later section to assess the overall economy of the CCU.
 

 The patient's economy

 Clearly the emotional and physical needs of the patient will vary considerably within the period of time he will be confined to the CCU. During the first hours, he is faced with the psychologic task of reorganizing his own conscious assessment of his mortality and of his priorities in life. In the initial minutes after his heart attack, he is concerned primarily with the physical pain and the effects of'the generalized stress reaction. He is facing death at that moment but is not entirely aware of it consciously. Instead, he is fighting the threat of death at very primitive physiologic and biochemical levels. Later, he will face the task of organizing his psychologic structure to cope with the fact of his mortality. He will also need to sort out his wishes and priorities for the future and he will have prominent concerns about his ability to function again in his career.

For some of this psychologic reorganization work he needs privacy; for other parts he will need a human being to listen to him as he thinks aloud; and for still other parts he will need active reassurance and accurate information about his physical condition so that he can once more begin to take control of his life and relinquish the dependent, sick role.

The patient's chances for having his need for privacy gratified early in his illness are practically nil; his vital signs and other bodily functions will be monitored with unceasing scrutiny by machines and people. Later, as long as he is in the CCU, the chances for gratifying his need to verbalize his feelings is equally small considering the observation that CCU nurses spend only about 1% of their time talking with their patients. Similarly, it is unlikely that he will obtain the full disclosure of information about his condition that he would like, because his physician is too busy to spend time educating him and the nurse is acting under implicit orders not to give any "medical information" to the patient.

If the patient is fortunate enough to share a close bond of affection and mutual interdependence with his wife, he may find that she is a resource to him emotionally. If, on the other hand, his years of heavy devotion to his career has served to distance him from his wife and family, his wife might meet his new need to talk with her with bewilderment and indifference.

Processes of psychologic reorganization following a severe traumatic event such as the patient has suffered usually take weeks and months to accomplish. By then, the patient will be out of the CCU environment and will have the opportunity to seek emotional support, guidance, and perhaps rehabilitation counseling through friends, a cardiac rehabilitation program, or a relationship with a psychotherapist. Of the four individuals described in this chapter, the patient has the best chance of achieving an emotionally healthy outcome from this encounter. Fig. 3-2 summarizes the patient's economy.



The nurse's economy

 The nurse has two major areas in her life that drain her: her job and her child. The income she receives from her job is virtually the only source of replenishment for her, but her life is organized in such a way that she receives very little emotional gratification from the money. A secondary, and largely symbolic, source of support she has is through the dependent relationship she has on the hospital. That relationship is definitely bittersweet. On the one hand, she achieves a vague sense of security by identifying with the larger institution as if it were a nurturing family. Also, the hospital is helping her by providing insurance benefits and a retirement plan, and she has the satisfaction of knowing that her job is secure as long as she does not cross the nursing director. On the other hand, she gives up a lot of autonomy because of her relationship with the hospital: She knows that she could be ordered to float to any floor where the administration needs "a body" to fill "a slot," she could be pressed into working a double shift at any time because of her susceptibility to manipulation by invoking her guilt feelings, and her chances of career advancement beyond her present salary scale are slim because she knows she could always be replaced by a "cheaper" nurse if she pressed her demands.

A third source of gratification for the nurse's dependency needs is through fantasy. By the mechanism of fantasizing the "ideal" husband, the nurse can pretend to gratify her need to have love and security in her life. That mechanism is not satisfying, however, because there is no real replenishment.

The fourth source of nurturing for the nurse is through the process of identifying with her patients. By that means, she can vicariously enjoy the gratification of their dependency needs by taking care of them herself. Needless to say, that device, like fantasy, only serves as a stopgap measure and will not retard the inexorable pathway to psychologic disorganization and collapse.

The nurse receives very little nurturing from her son; instead, he depends on her and makes his demands known more insistently than all of her patients put together. In return, he offers her little for herself except the occasional time when she permits herself to regress and play with him.

As indicated in the vignette about the physician, the nurse receives very little emotional support from him. Although he accurately identified her distress of the moment and was compassionately drawn to offer her something, the exigencies of his own life at the time required that she be a nurse, not a person. As a result, the weu-meant compliment to her professional skills served only to intensify her sense of need for warm human contact.

The nurse receives little more than money from the hospital administration. Her head nurse, insecure in her own job, is motivated to keep the nurse in her present position-quietly efficient, uncomplaining, and generally enhancing the image of the head nurse. The nursing director is more overtly hostile and is interested primarily in devaluing the nurse rather than building her up.

Compared with the other three individuals in this system, the nurse has the poorest outlook for achieving mental health without intensive psychotherapy. Because of the strongly negative balance of her emotional economy (Fig. 3-3), she is a prime candidate for severe depression within the next few months or years. As an alternative to psychotherapy and its attending reorganization of her internal mechanisms (reprogramming), the nurse might change external factors instead, which could lead to an improved economy. For example, she could quit nursing altogether as so many nurses do, she could ally herself with an organization that sympathizes with her feelings such as a union or employees' association, or she could enter administration, thereby hoping to enhance her emotional economy by acquiring power.

 

The physician's economy

The physician is better able than the nurse to maintain an emotional steady state economy. His output is as great or greater than the nurse's, but he has more sources of replenishment than she does. The respect he holds in the community is much greater than that of the nurse and his patients are much more demonstrative than hers of their feelings of appreciation. Even the nursing director provides support for him; overbearing to her subordinates, nevertheless she is obsequious to those whom she perceives as her superiors. Even at home, the doctor receives a degree of nurture. He and his wife and children are not a close family emotionally, but his wife appreciates her standard of living and frequently shows her appreciation to the physician.

Unlike the nurse, the physician also uses fantasy to fulfill his emotional needs for dependency. His fantasies tend to be sexual in which his dependency needs are met by passive, responsive women. In that way, he can maintain a position of control while having his needs "serviced." In other areas, fantasy represents a threat to the physician. Because of his acquired programming, the physician feels he is extremely fragile and therefore vulnerable to any change in the status quo. He is programmed to believe that if he has dependency needs, he is weak, and if he is weak, he will not be able to control his emotions and his life, and if he is unable to control those, he will be useless and unnecessary. Predictably then, he recoils from introspection-both psychologic and physical. He refuses to deal with the dizzy spells because he refuses to acknowledge the fact that he might be forced into a state of dependency. Similarly, he refuses to seek emotional help, instead scoffing at psychiatry and calling it "witchcraft. "

The emotional prognosis for the physician depends largely at this point on his physical health. Although he is very near an emotional steady state now (Fig. 3-4), if he is stricken by any of the serious illnesses heralded by dizzy spells, his true fragility will be revealed. His programmed internal organization that is designed to maintain his sense of self-esteem will be thrown into a state of chaos as a result of having his primary prop knocked out from under him-his work

The nursing director's economy

 Because of her acquired programming, the nursing director perceives herself as a "closed" system; in her own self-referencing way, she believes she is completely self-contained and needs no one. In fact, she does need others and her uninterrupted obsession with acquiring power over others has kept her in positions by which she cannibalizes her subordinates as if she were an infant sucking at her mother's breast.

The nursing director's programming (character structure) is typical of that of many people who scratch and claw their way to the top. So much energy was involved in organizing her psyche to survive her first 2 years, she has never given up the grandiose, infantile (narcissistic) world view. incapable of empathy, intimacy, or loyalty to others, she is socially isolated and is able to suck sustenance from others only because she holds power over them. Her emotional economy is satisfactory as long as she holds power. In that way, she is as content and stable as the infant with a slave/mother and a plentiful supply of food, clothing, and shelter (Fig. 3-5.)

Because of her highly self-referenced world view, the nursing director resembles infants in another important way: She uses the same primitive mechanisms of dealing with unpleasant emotional experiences such as hatred and aggression. She simply attributes those feelings to others in a paranoid style, thereby viewing any other important person ag a threat to her security. Not surprisingly, many of these projected feelings are accurate; she is widely hated and many people wish her dead. In other words, her belief that she is hated and persecuted is accurate, but her way of acquiring that belief was invalid. (The criterion for defining paranoia is not whether a person's beliefs are true, but rather whether his mechanism for acquiring those beliefs is logical within the context of his environment.)

The life crisis that is expected to throw the nursing director's emotional economy into disorganization is suggested in the preceding. If she loses power over people, she will lose her main source of sustenance. Accordingly, as her physical and intellectual energies diminish with age thereby leaving her without the means for satiating her voracious appetite for power, she can be expected to withdraw into a paranoid state equivalent to depression in others
 

 THE ECONOMY OF THE CCU

 The foregoing illustrates that each subsystem within the CCU is itself an incredibly complex system. Examination of the whole CCU system, then, involves examination of the interactive processes among them. In bringing the subsystems together an organization is formed. An organization is a system corhprising individual human beings. Organizations can be considered either formal or informal; an example of a formal organization is the CCU, whereas an example of an informal organization is a group of people who come together more or less regularly to drink beer and relax at the end of the work day. Formal organizations are generally established to meet a particular goal. In the case of the CCU, the organizational goal is to provide critical care support for the acutely and severely iU.

The formal goal orientation, however, is not the only orientation to be found in the unit. As seen in the foregoing sections. each subsystem, or individual, within the unit has its own set of goals. Some of these goals are complementary and others are contradictory. For example, the nurse and the physician share the goal of helping others even though each has come to this goal through his or her own experience and programming. The nurse and physician also have contradictory goals: The nurse is longing for personal support and validation of her individual needs, whereas at the same time, the physician's goal is to provide a nurse for his patient. Similarly, the nurse and nursing director have complementary goals: They both want the patient to survive although their reasons for that goal are very different. A contradiction in goals is represented by the nurse's need to be super competent, which conflicts with the nursing director's wish that the nurse will make mistakes and lose her status.

A combination of the complex flows of energy among the four human subsystems of the CCU is represented in Fig. 3-6. Simplification of the diagram is accomplished by considering only the net flows of energy for each individual and arranging the subsystems in linear order according to their rates of entropy change (Fig. 3-7). Arrangement of the subsystems in that form is analogous to cascades of batteries connected in series. The potential energy for each level is diminishing and the entropy is increasing with the current drain. Also, by analogy, the flow diagram represents at the top, a "source" of energy and at the bottom a "sink."

!ccu-f7.JPG Inspection of the flow diagram of the CCU system shows at a glance that the system is not in equilibrium. Further, it is in steady state only if the rate of flow into the system equals the rate of flow out of it. Referring to the individual economies of the source individual (the nurse) and the sink (the nursing director), it is clear t44t the system is not in steady state. Presumably, the overall gain in entropy of the CCU system must be accounted for outside the CCU.

The principle of conservation of psychic energy dictates that prevention of an increase in the entropy of the CCU must be "paid for" by its suprasystem or set of suprasystems. Qualitatively, payment of this debt can be demonstrated by several factors common to hospital economics: (1) a high rate of turnover of nursing staff,,' (2) a high incidence of absenteeism due to "illness," (3) unconscious sabotage of patients leading to malpractice lawsuits, (4) increases in worker's compensation insurance rates as a result of on-the-job casualties, both physical and emotional, and (5) increased reliance on expensive registry nurses. Low staff cohesiveness and low morale are both measures of high entropy states.

These costs are ultimately measurable financially. The largest single budget item of any hospital is the payroll. Insurance rates, orientation costs, and sick leave compensation contribute significantly. The impact of the cost factors just listed is to raise the cost of hospital care without improving services. These costs, of course, are paid for by the consumer, whether directly, through insurance premiums, or by taxes. It is my assertion that the increase in hospital costs in the past two decades is contributed to significantly by the systematic disregard of the emotional economies of hospital employees.

These emotional forces are potent. To ignore them is to permit no control over their effects, whereas to acknowledge them is to enable constructive channeling of information and energy. Examples of destructive processes within critical care units along with the correction of those processes are provided in a study I have made.3 The principles of liaison psychiatry are not discussed in this chapter except in this general sense: If people in an organization can be helped to understand the emotional undercurrents in the processes of the system, relief can be obtained from disruptive "symptoms" and internal sabotage. Modem management techniques incorporate that principle.
 

 PREDICTIONS BASED ON THE ECONOMIC MODEL

 Assessment of the economies of the CCU system and its suprasystem, the hospital, permits several general predictions of effects.

First, because of the intrinsic resistance to change exhibited by hospital management in general, it is easy to predict that things will get worse before they get better; costs will continue to rise as productivity declines.

Second, because the hospital industry has little understanding of the mechanisms of the emotional costs in hospital systems, it has little control over the rapid decrease in cost-effectiveness of hospital care. Predictably, based on the cherished concept of nurse/chattel, administrators will try to squeeze more "giving" out of nurses, but the nurses will resist more.

Third, as a result of the attempts to get more from nurses, nurses will continue to leave their careers early after only brief exposure times. The staff turnover rates will get even higher as job dissatisfaction grows and will be highest at the poorest managed hospitals.

Fourth, in attempts to find more personal autonomy, more nurses will leave hospital staffs and begin working for registries. By this mechanism, nurses have already acquired much more power than hospitals are willing to acknowledge and deal with directly. Instead, they are attempting to form cartels through their own registries.

Fifth, as the adversary lines are drawn more boldly between labor and management, the registries will be supplanted by nurses' unions that will focus on improved working conditions, more nurse representation in hospital decision making, better patient care, and portable pension plans. As these effects become national in scope, there will be increased pressure from congress to control hospital costs and thereby to control the quality of medical care. Bureaucratization could supplant professionalism entirely. Professional ideals are internal to professional people and tend to drive them toward flawless performance, which is not possible. Still, the results of externalized application of ideals are well known: Bureaucratic ("socialized") medicine in the United States has proven disastrous. State mental hospitals, county hospitals, Veteran's hospitals, Medicare- and Medicaid-controlled programs offer low-quality, rationed care at exorbitant costs.

Finally, the economic systems analysis suggests solutions to the problems: By sharing the control of patient care institutions with professionals who are motivated to provide that care, the hospital industry can promote establishment of healthy steady-state hospital systems. This would require elimination of exploitative practices and of cannibalistic administrators.
 

 SUMMARY AND CONCLUSION

 An organization can obtain steady-state stability only by adhering to, rather than trying to fight, the laws of nature. Modern business management takes into account not only the traditional social science of economics but the science of psychology as well. One reason the hospital industry is saddled with archaic management techniques is the reluctance of people in the allied health professions to emerge from the dark ages and to acknowledge that human beings are systems comprising both physical and psychologic subsystems.

One lesson to be learned from the national sociopolitical-economic perturbations of the last 40 years is that while the economy can be manipulated, economics cannot be. Similarly, the laws of psychology cannot be manipulated. Most members of the health professions are aware that the legislative schemes proposed by some politicians to achieve cost reduction, consumer satisfaction, and quality medical care are spectacles as absurd as trying to repeal the law of gravity. Nevertheless, some of these same people deny the significance of psychologic processes in themselves and in others.

To be cost-effective and stable, a system must conform to certain principles of reality. Specificauy, no system is "closed," and no individual or system economy can survive indefinitely in negative balance. Accordingly, it is important to acknowledge that all human systems are "affectopen," which means that the flow of emotional information is free and significant. ("Affect" means both the internal experience of feeling and its external expression, as by facial expression, for example.) Therefore an "affect-closed" system does not exist. Nevertheless, hospitals are replete with policies and procedures that are based on the assumption that patients, nurses, physicians, and administrators are each weu-encapsulated, highly controlled, and always predictable automatons.

In that never-never land, hospital employees can be assumed to have no needs other than those o physical subsistence. Those hospitals operate on the same assumptions of hospitals of a generation ago by which nurses and other employees were the chattel of the hospital and could be deployed as needed without regard to their individual needs and agendas. This is an assumption that contradicts the fact that within our culture, considerations of a worker's needs and wishes are "rights" that were won by bloodshed but are now taken for granted.

There are prominent signs in our current health care crisis that point to serious states of costly disorganization ("disease"): Nurses are extremely ambivalent about their profession and tend to blame "the administration" for most of their problems'; nurses from registries are replacing permanent hospital staffs, pushing up the costs of nursing service; administrators are frustrated and angry about being squeezed by the demands of government, physicians, patients, and nurses; nurses are increasingly demanding recognition as "true professionals" on the one hand but seem unwilling to tolerate the demands of 24-hour-a-day professionalism on the other; some members of the public are calling for "free" medical care at the same time that physicians are demanding that they not be asked to "give" so much; and politicians are pushing to take over medical care despite their proven inability to provide quality care. It is obvious that the health professions need to achieve a stable steady state.

To accomplish that, the psychologic needs of all people involved must be considered. Therefore the medical leadership and hospital management must recognize and deal with the emotional needs of the helping people as wefl as those of the helped.

Strategic planning to modernize hospital management can begin immediately, Short-range recommendations include: (1) Hospitals should provide adequate insurance coverage for employees that covers psychotherapy by psychiatrists, psychologists, and psychiatric social workers; (2) hospitals should provide continuous liaison services by mental health professionals to those units with the highest stress levels; and (3) hospitals should develop and formalize measures to promote staff/management interactions and to facilitate feedback from the staff in development of hospital policies.

Longer range recommendations include: (1) Hospital administrators should educate themselves with management consultants to take advantage of knowledge and methods already available; (2) the Joint Commission for the Accreditation of Hospitals (JCAH) should develop criteria for assuring that only wetl-managed hospitals are accredited; (3) schools should emphasize more the psychology of hospital employees in their curricula for hospital administrators; and (4) researchers in the field of hospital management can assess administrative practices by relying more on the evaluations of supervisors by their subordinates.
 

 ACKNOWLEDGMENTS

 I gratefully acknowledge many stimulating and thought-provoking conversations with George A. Michael of the Lawrence Livermore Laboratory as well a the staff and administration of Santa Ana Psychiatric Hospital, but I accept full responsibility for the opinions herein. This work was supported by Donald E. Watson, M.D., Inc., a California professional corporation.
 

 REFERENCES

 1.Hay, D., and Oken, D.: The psychological stresses of intensive care unit nursing, Psychosom. Med. 34:109, 1972.

2.Koumans, A. J. R.: Psychiatric consultation in an intensive care unit, J.A.M.A. 194:163, 1965.

3.Watson, D. E.: Psychiatric liaison services to the critical care nursing staff, Critical Care Update! 4:5, 1977.

4.Godfrey, M. A. and Nursing 78: Job satisfaction—or should that be dissatisfaction? Nursing 78 89, 105, 1978.

5.Seybolt, J. W., Pavett, C., and Walker, D. D.: Turnover among nurses: it can be managed, J. Nurs. Admin. 8:4, 1978.

BIBLIOGRAPHY

Miller, J. G.: General systems theory. In Freedman, A. M., Kaplan, H. 1. and Sadock, B. J., editors: Comprehensive Textbook of Psychiatry/II, Baltimore, 1975, The Williams & Wilkins Co. p. 75.

Porter, L. W., Lawler, E. E., 111, and Hackman, J. R.: Behavior in organizations, New York, 1975, McGraw-Hill Book Co.

Kramer, M.: Reality shock: why nurses leave nursing, St. Louis, 1974, The C. V. Mosby Co.

Porter, L. W., and Steers, R. M.: Organizational work and personal factors in employee turnover and absenteeism, Psychol. Bull. 80:151, 1973.

Tirney, T. R., and Wright, N.: Minimizing the turnover problem: a behavioral approach, Supervisor Nurse 4:47, 1973.

Brief, P. P.: Turnover among hospital nurses: a suggested model, J. Nurs. Admin. 6:55, 1976.