My wife and I have been spending quite a bit of time in the NICU. She gave birth to our first children, fraternal twins Ryan and Madeline.
(Like backstories and context? Keep reading. Otherwise, go to Part 2.)
Part 1: The Personal Story and Current Journey
All things considered, we are very lucky. While born 8 weeks and 3 days early, we have according to medical professionals, healthy kids. Their small size, fragile appearance, the CPAP obscuring their face, the IV in their arm, and multiple connectors to constantly measure heart rate, oxygen saturation, and respiratory rate make it very difficult for us to feel they are healthy and progressing as they should.
Knock on wood, they have not needed any surgeries, transfusions or significant intervention. They are starting to put on weight, are able to eat, sleep, and poop, all things that we cannot take for granted, especially when all we have to do is look at some fellow NICU-mates whose struggles are much greater than our own.
After the first week, we started seeing noticeable differences between our boy and our girl. The medical staff set our expectations for her to develop much faster than him, and that has been the case. She has grown faster, consumes more, and most importantly, can spend time off CPAP. He on the other hand has not shown many signs of progress. Had we only one kid and had we just celebrated his two week birthday, we might feel differently.
Instead of two steps forward and one back, it feels like one step forward and two back with him. The nature of the NICU is partially to blame. In many ways, it is the definition of stressful, and it also epitomizes the squeaky wheel gets the grease. Each of the three continuously monitored metrics has an acceptable range, and if any of them outside the range, an alarm goes off. Sit in the NICU for more than a few minutes, and that's what you hear. With our boy, it's what we hear seemingly non-stop. It's a form of torture. You have few to no tools at your disposal to assist, and your mind can only focus on the alarms.
With three babies in a nurse's care generally, someone needs something almost always, so it's anything but calm or easy. The issue is not just the feeling of helplessness, it's the balance between what is measurable, trackable, and known versus the unknown and thus subjective.
The balance, or imbalance in this case, also leads to something else, a high sensitivity (on my part at least) to our babies' nurse. "Hospital" may be close to "Hospitality" in spelling, but that's where the difference ends...on so many levels. Let's look at one. Unlike your typical higher-end hospitality environment, the nurses are very much people with individual styles and personalities. There is not a higher brand and code under which they operate. That is not a criticism, but when assigned a personality and style that does not match your own, it adds additional friction to an already charged situation.
Part 2: Connected-Future and the Unknown
Having had a wide range of nurses has led to many observations, especially about our medical system, but a way to frame our experience not just this experience but others as well. It stems from balancing good enough with doing all that can be done. In so much of our life, this is what good versus great looks like, or hard work versus less hard work, etc.

In sports especially, we see the difference between hard work versus not as hard work. In school, we see it too, and it often looks like this. You know what you have to put in to get to good enough, and some choose to do more. It can be personally motivated (just a high achiever) or reward driven (achieving highly to get to a good school).

If you want to raise performance, you have to either install a minimum threshold or raise it.
When situations aren't as measurable, at least in the connected-future*, that's where it gets hairy. The NICU that our babies are in is rated very highly, but that's because they do many procedures on difficult cases. The actions taken have measurable results and in the connected-future. This is where you want to be when certain neo-natal procedures might be needed. But, what if there isn't a procedure? Then, there is a prescribed course of action that revolves around monitoring and "good enough."
Our nurses tend to fall into two camps. Those that optimize to good enough and those that optimize to all that could be done, even if the results of those actions can't be felt in the connected-future. Some are high achievers, others not as much. Some are just driven because they can't live life not giving it what they can; others are satisfied at giving just enough. In other words, nurses are people personified.


Why we care about is that this isn't a restaurant; it's our kids lives. The potential delta between good and great is immeasurable and exponential. How much more could you do and have if you were 1% better? 5%? 20%? 50%? In the NICU, we're talking about kids in the very beginning of what any parent hopes will be a long, fulfilled life. How can we not obsess at what good enough and better than good enough means for them - mentally and physically. That more than the constant alarms eats at me. CPAP not bubbling consistently but "good enough?" Oxygen saturation low but "good enough?" A greater number of bradies, where they recover but with a lower low? No one knows what it means. The high achievers try to make sure more time is spent well above good enough. The other group doesn't try to optimize for achievement. There is no connected-future incentive that would force a good enough achiever to reach higher. The result. This.
Without better metrics, we struggle to optimize to anything but the minimum, as it relies on people doing more just because. And, when the potential difference between good enough and better than good enough can be immense, not having tracking commiserate to the gravitas of the situation creates an imbalance in the parties and potentially toxic scenario. 90% of a great meal is very different than 90% of a great life. This situation isn't unique to being in the NICU, but it highlights the gap in a unique way.
As my father would have said, "Way to over think it." Give me some proof that it doesn't matter, and maybe I'd agree. Until then, for me it's all about alignment and optimizing.
*The connected-future means a timeframe where a person responsible for an action feels the real result of the action. By and large humans optimize for the connected-future not the eventual-future, because our system of incentives places the maximum benefit on the connected-future instead of the eventual-future. Alignment of incentives and the disconnect between for what we are generally incentivized and what we should be incentivized is a topic of extreme interest to me.