# Situation: A 52-year-old man is in the intensive care unit (ICU) with septic shock and acute kidney injury. He is intubated and receives mechanical ventilation. Because his platelet count is low, he is on continuous kidney replacement therapy (CRRT) with regional citrate anticoagulation. During a sudden fall in his oxygen saturation, the nurse and the respiratory therapist disagree loudly about whether to suction him or bag him first. The attending intensivist, who is leading, decides at once and directs each person's task. Why is this directive approach appropriate here?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630260  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 52-year-old man is in the intensive care unit (ICU) with septic shock and acute kidney injury. He is intubated and receives mechanical ventilation. Because his platelet count is low, he is on continuous kidney replacement therapy (CRRT) with regional citrate anticoagulation.

During a sudden fall in his oxygen saturation, the nurse and the respiratory therapist disagree loudly about whether to suction him or bag him first. The attending intensivist, who is leading, decides at once and directs each person's task. Why is this directive approach appropriate here?

## 보기

1. A crisis needs one quick decision; talks can follow in a debriefing **✔ 정답**
2. It lets each side give up part of what it wanted to reach agreement
3. It keeps the relationship between the two staff members intact
4. Directive decisions produce the most lasting team commitment

**정답: 1**

## 해설

The competing, or forcing, mode is appropriate in emergencies and safety issues, when there is no time for discussion. The team leader decides immediately so care is not delayed, and the disagreement is examined later in a debriefing.

## 심화 해설

Why the directive approach fits this crisis

A sudden oxygen desaturation in an intubated patient with septic shock is a time-critical, high-stakes event. The patient already has acute kidney injury requiring CRRT, low platelets, and hemodynamic instability from septic shock. Any delay in restoring oxygenation can rapidly worsen tissue hypoxia and trigger further deterioration. In this context, the competing (forcing) conflict mode is not about winning an argument; it is about protecting patient safety when time does not allow consensus-building. The intensivist makes one immediate decision and assigns each team member a specific task, so care proceeds without interruption.

Key point! The competing mode is reserved for emergencies and safety threats, not for routine disagreements. It trades speed for collaboration, which is exactly what a desaturation episode demands.

The loud disagreement between the nurse and the respiratory therapist is a normal human response under stress, but it creates a dangerous pause. In crisis situations, team performance depends on a clear, single decision-maker who can cut through role ambiguity. Research on intensive care team leadership emphasizes that senior physicians report using directive behaviors precisely when the clinical situation is unstable or deteriorating . The leader’s role is to restore order, assign roles, and keep the team focused on the immediate physiological priority—here, the airway and oxygenation.

A directive decision does not end the conversation permanently; it postpones discussion until the patient is stable. The debriefing afterward is the appropriate place to examine why the disagreement occurred, whether suctioning or bagging should have been prioritized, and how the team can communicate more effectively next time. This aligns with crisis resource management principles, where immediate action and later reflection are both essential .

| Conflict mode | Best used when | Risk in this scenario |
| --- | --- | --- |
| Competing (forcing) | Emergency, safety threat, no time for discussion | Low if leader is correct; high if used routinely |
| Compromising | Both sides give up something; moderate time pressure | Delays oxygenation while negotiating |
| Accommodating | Preserving relationship matters more than the issue | Patient safety cannot be traded for harmony |
| Collaborating | Complex problem, time available, commitment needed | Too slow for a desaturation crisis |

The other options describe different conflict-handling intentions. Option 2 describes compromising, where each party gives up part of what it wanted. Option 3 describes accommodating or smoothing, which prioritizes the relationship over the task. Option 4 is factually incorrect: directive decisions produce quick compliance, not lasting commitment. Watch out! In an emergency, the goal is immediate correct action, not team consensus or relationship preservation. Those concerns are addressed later, after the patient is stabilized.

In trauma resuscitation and other high-acuity settings, effective leadership is recognized as a determinant of team performance and patient outcomes, yet it is often underemphasized in training . The intensivist’s directive behavior here is an example of crisis leadership: recognizing that the situation has shifted from a collaborative mode to a command mode. Healthcare action teams operating under high-pressure, time-sensitive conditions depend on this kind of role clarity to avoid task conflict from paralyzing the team . The nurse and respiratory therapist may still disagree, but they do not need to agree to act; they need a single, clear instruction.

The debriefing after the event serves a second purpose beyond resolving the suction-versus-bag question. It allows the team to examine communication patterns, role expectations, and whether the directive decision was clinically correct. This reflective step helps build the shared mental model that makes future crises run more smoothly .

## 임상 시나리오

Crisis Leadership in Acute DesaturationWhen to use the competing mode in the ICU
A sudden oxygen desaturation in an intubated patient with septic shock is a time-critical emergency. The competing (forcing) mode is appropriate because any delay in restoring oxygenation can worsen tissue hypoxia and trigger further deterioration.

The team leader makes one immediate decision and assigns each member a specific task. This cuts through role ambiguity and keeps the team focused on the immediate physiological priority: airway and oxygenation.

CautionThe competing mode is reserved for emergencies and safety threats, not routine disagreements. The loud disagreement is examined later in a debriefing, not during the crisis.

## 핵심 개념

- **Competing (Forcing) Mode** — A conflict-handling style where one party pursues its own concern at the expense of others; appropriate in emergencies and safety issues when time is critical.
- **Debriefing** — A structured review held after a critical event to discuss what happened, resolve disagreements, and improve future team performance.
- **Septic Shock** — A life-threatening condition of organ dysfunction caused by a dysregulated host response to infection, with persistent hypotension requiring vasopressors.
- **CRRT** — Continuous kidney replacement therapy; a slow, continuous form of dialysis used in hemodynamically unstable ICU patients.
- **Regional Citrate Anticoagulation** — A method of preventing clotting in the CRRT circuit by infusing citrate into the blood before the filter, chelating calcium locally.

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