Read an Excerpt
A Case Study of Intuition
I don't think you can make effective decisions without developing your intuition. To illustrate why intuition is so important, I've selected an incident that contrasts two nurses, each facing the same crisis. One of the nurses has developed intuitive decision-making skills and one is trying to acquire these skills.
The example describes the decision making of nurses working in an NICU. That stands for neonatal intensive care unit, the hospital ward where they keep close watch on newborns in critical condition.
Most of the infants in an NICU have been born prematurely. Some weigh a pound or less, and many are born with underdeveloped respiratory, circulatory, or immune systems.
Each infant is placed in its own isolette or medical bassinet, and attached to little adhesive leads that provide data to a bank of monitors displaying heart rate, blood pressure, respiration, blood oxygen level, and other vital statistics. Nourishment might be provided through an IV (intravenous feed) or through a drip tube snaked down the esophagus directly into the stomach. A thermostat precisely controls the temperature in the isolette.
One of the risks in the NICU is the danger of infection. To gain access in order to see and hold their babies, parents perform a five-minute surgical scrub from hands to elbows. Children are strictly prohibited because they are exposed to so many germs and can easily transmit them to the babies.
Homemade get-well cards and photos of Mom and Dad, brothers and sisters, cousins, and family pets are often taped to the glass walls of the isolettes. A small rubber toy, such as a Mickey Mouse or Winnie the Pooh figure, might be placed in the isolette as a companion, but only after first being sterilized by the nurses, because a stuffed animal might carry dust mites.
Feedings have to be carefully calculated. The goal is obviously to help the baby grow, but it is equally important to make sure the baby does not add body weight faster than heart and lungs can support. Not only is nutrition intake carefully measured, but so is the waste coming out the other end. Every diaper is weighed to gauge the baby's metabolism. Practically every aspect of intensive care in the NICU involves continuous monitoring and adjustments to maintain a precarious balance in these fragile human systems until the babies can grow themselves into stability.
During the day a steady procession of medical technicians comes through to take blood for routine testing, perform sonograms or other procedures, administer respiratory therapy, or deliver medications. But it is the primary NICU nurses who are on the front lines. They are responsible for administering the treatments established by the physicians, monitoring the baby's condition, and being alert to any signs of change.
With infants in these fragile conditions, many things can go wrong, and practically all of them can become life threatening. One of the greatest and most common dangers is sepsis, a systemic infection that spreads throughout the infant's circulatory system. Sepsis can be deadly, especially for low-birth-weight babies. Premature babies come into the world with an underdeveloped immune system, making them particularly vulnerable. The first line of defense against infection is the baby's intact skin and mucous membranes, but in the NICU, that defense has been penetrated by IVs, catheters, and other invasive measures. Sepsis can be detected by a blood culture, but this test takes twenty-four hours and by then the baby might be overwhelmingly infected and beyond help. The onset of sepsis is often accompanied by very subtle changes in the baby's status. The nurses' ability to recognize these subtle changes is the key to early detection of sepsis and appropriate intervention. The nurses in the NICU must be continuously on guard against the potential danger of infection.
Some infants spend only a couple of days in the NICU. Some are there for several weeks or more. And some do not survive. The nurses must also deal with this reality.
Some nurses find the challenges and the mission rewarding and choose to make neonatal intensive care their career. However, many nurses new to the NICU burn out in less than eighteen months, overcome by the complexities and unrelenting stress of caring for the tiny lives in the balance.
"Darlene" was a good example of someone who flourished in this environment. At the time of this incident she had become the assistant clinical coordinator for the NICU. This meant that in addition to working regular shifts on the ward, she was responsible for scheduling, hiring, and firing other nurses. Darlene had a bachelor of science degree in nursing. All of her nursing experience was with babies, and she had spent the last six years working in the NICU.
"Linda" was also an experienced nurse, although she was new to neonatal care and was, therefore, still considered a trainee. She had completed her orientation in the NICU and was working shifts on the floor, mentored one-on-one by Darlene, although they each had responsibility for different infants. The two had been working together this way for several months, so by now Darlene was doing more monitoring than instructing.
A Baby in Crisis
Linda had primary responsibility for an infant girl, "Melissa." By NICU standards, Melissa was not a particularly tough case. Melissa was a "preemie" and tiny like most of the babies in the NICU, but she had no major problems that had to be overcome. She simply needed a little support until she could grow herself out of danger. She was not on a ventilator. She was able to take small amounts of formula in a bottleup to two ounces at a timeand her young parents had even been able to hold her during feedings. She was putting on weight, and all signs indicated she was on the road to becoming a healthy baby girl.
It was early in the morning, and Linda and Darlene were nearing the end of an uneventful shift. Thankfully, there had been no emergencies. If anything, Melissa had been less fussy than usual. Maybe this was a sign that she was getting better. The ward was quiet and deserted except for the infants and their nurses. Like most visitors, Melissa's exhausted parents had gone home after keeping vigil during the day. The lights on the ward were turned low, except for a small light at each station that allowed the nurse to do her workan ongoing routine of taking temperatures, changing diapers, feeding, administering medicines, recording readings from the monitors, and adjusting settings on the equipment in accordance with the treatment prescribed by the physician. Frequently an alarm would sound from one of the babies' monitors, but almost invariably it was a false alarmusually a lead had come loose, interrupting the data input. A nurse would appear, calmly check the situation, and reset the monitor. Occasionally, a baby would fuss, and a nurse would respond. Otherwise, the ward was quiet.
During her scheduled feeding Melissa had seemed a little lethargic, but who wouldn't be at that hour? Linda had regularly checked Melissa's body temperature and found it a little low over several checks, though still well within the normal range. She turned up the thermostat in the isolette each time to make Melissa more comfortable. Late in the shift a medical technician had come in to take a routine blood sample for testing. This had been done by a heel stick, a small prick made in Melissa's heel. The technician had covered it with a small, colorful Band-Aid. A good med tech will make an almost imperceptible heel stick that closes up almost immediately. A sloppy heel stick might bleed for a few minutes. Melissa's heel stick was bleeding a little bit, creating a dark blot on the Band-Aid.
Melissa was Linda's patient. Darlene had talked to Linda several times about her, but by this point in the training she did not routinely check Melissa herself.
But when Darlene walked past Melissa's isolette near the end of the shift, something caught her eye. Something about the baby "just looked funny," as she later put it. Nothing major, nothing obvious, but to her the baby "didn't look good." Darlene had a closer look, now noticing specific details. She noticed the heel stick had not stopped bleeding. To Darlene, Melissa seemed a little "off color" and "mottled," and her belly seemed a little rounded. She noticed this even though every baby had a different complexion and body shape and Darlene was not particularly familiar with Melissa's normal state. A quick physical exam confirmed that Melissa still had an unusual amount of residual food in her stomach, causing bloating. Darlene checked Melissa's chart and noticed that the baby's temperature had dropped consistently over the shift. She called Linda over and asked her if the baby had seemed lethargic during the shift. When Linda replied, "Yes," Darlene immediately raced to the phone and woke the duty physician.
"We've got a baby in big trouble," she said. She explained the symptoms. The physician agreed with Darlene's assessment of a baby in crisis and immediately ordered antibiotics and a blood culture. Twenty-four hours later, the blood culture confirmed sepsis. If they had delayed giving the antibiotic until they had the results of the blood culture it would probably have been too late.
This story has a happy ending. Thanks to an experienced nurse's intuitive sense of a baby who "didn't look good," Melissa would live.
Initially, Darlene was incredulous that Linda had missed the classic symptoms of sepsis, which seemed so obvious. All the new nurses were trained to be alert for signs of it.
In fact, Linda had recognized practically all the individual symptomsbut most of them could be reasonably explained in several different ways.
Linda had noticed the decrease in Melissa's temperature. But because the temperature had never dropped out of the normal range, Linda had responded by increasing the heat in the isolette after each reading, four times in a row. This seemed like a reasonable response because, usually, it is a fever that is worrisome to a nurse, not a temperature drop. Darlene, however, knew from experience that a drop in temperature could signal a coming fever.
Linda was aware of the bleeding heel stick, but did not know how quickly the bleeding should stop in a normal baby. Plus, the bleeding could have been the result of a sloppy heel stick. Darlene knew that the continued bleeding was another danger sign.
Linda had noticed that Melissa seemed "sleepy"she didn't label this as lethargicbut she knew that babies tended to sleep a lot.
She was able to recognize the rounded belly and mottled skinpossible signs that blood supply to the skin could be shutting downwhen they were pointed out to her, but earlier she had not attached any significance to these cues. Linda had already learned that the newborns in the unit sometimes got lighter or darker for no apparent reason, and as their digestive systems matured she expected there would be times when they would become bloated. Darlene, though, had noticed a subtle olive tinge in Melissa's complexion and associated it with a possible infection; Linda could recognize the coloring but hadn't realized its importance.
Ultimately, it was not so much the individual symptoms that were key, but a particular constellation of symptoms. Linda could see all the signs, but she was unable to piece them together into a story that revealed the larger pattern.
During our interview with her, Darlene allowed that it is very difficult to know the signs of sepsis "until you see them."
In our research we found that Darlene was typical of highly experienced NICU nurses who can detect sepsis in premature infants, even before the blood tests pick it up. By noticing the early signs of sepsis these nurses were able to start treatment early and save the lives of babies. Some cues had been recorded previously in the clinical literature, but many of the cues that these nurses could recognize had never even been previously identified (and, in fact, our study resulted in a sepsis handbook for NICU nurses).
What You're Going to Learn
Darlene took one glance and her intuition told her Melissa wasn't okay. What was the nature of this intuition? You'll find out in Chapter 2, Where Do Our Hunches Come From?
Darlene developed her intuitive decision-making skills over many years and many babies like Melissa. You can build these skills more quickly through the techniques introduced in Chapter 3, Intuition Skills Training: Speeding Up Your Learning Curve.
Darlene did not simply rely on her intuition. She also sought information that might confirm or weaken her judgment about Melissa. You will learn how to blend intuition with analysis in Chapter 4, Using Analysis to Support Our Intuitions.
Darlene decided that this was a crisis and that Melissa needed antibiotics. What type of decision process did she use? See Chapter 5, How to Make Tough Choices.
Darlene's intuition enabled her to zero in on the sepsis that was starting to ravage Melissa. You'll understand how to use intuition to detect potential problems while they are still treatable in Chapter 6, How to Spot Problems Before They Get Out of Hand.
Darlene knew which data to seek from Linda, and which data to let go. She did not order tests before bothering the physicianjust the opposite. She called the physician to get antibiotics started before getting the results of the blood tests. You will learn how to use your intuition to handle ambiguity in Chapter 7, How to Manage Uncertainty.
With the data she collected, Darlene confirmed that Melissa was in trouble. The ways you can use your intuition to make sense of events are described in Chapter 8, How to Size Up Situations.
Darlene thought that the directions she had given Linda were sufficient. But they weren't. You will learn to effectively convey your intuitions to others in Chapter 12, Executive Intent: How to Communicate Your Intuitions.
Darlene and other NICU nurses report that the subjective nature of the assessment can make it difficult to share with novice nurses. Nurses have trouble articulating in detailed and specific terms what they are noticing intuitively. You can help subordinates come up to speed more quickly by using the guidance offered in Chapter 13, Coaching Others to Develop Strong Intuitions.
Darlene was not misled by the data records. She studied the trend of Melissa's temperature readings, and focused on the feeding charts that suggested that Melissa was having trouble digesting her food. You can use your intuition to actively interpret data instead of passively tending to the records the way Linda did, by applying the advice presented in Chapter 14, Overcoming the Problems with Metrics.
Darlene had learned to look at babies instead of depending on the monitoring equipment. To keep from becoming a slave to information technology, read Chapter 15, Smart Technology Can Make Us Stupid.