2/18/2010. A Holistic Framework for Nursing Time. Disclosure. ObiecliVes. Conventional Approach. Implications for Theory, Practice, and Research

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1 Disclosure A Holistic Framework for Nursing Implications for Theory, Practice, and Research Terry L. Jones PhD, RN Assistant Professor Clinical Nursing University of Texas at Austin 2007 NIH Clinical SCholar, UTSWMC This presentation was supported by Grant Number UllRR024982, titled "North and Central Texas Clinical and Translational Science Initiative" (Milton Packer, MD, PI) from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH) and NIH Roadmap for Medical Research, and its contents are solely the responsibility of the author and do not necessarily represent the official view of the NCRR or NIH. Information on NCRR is available at httd: Ilwww.ncrr.nih.aov/. Information on Re-engineering the Clinical Research Enterprise can be obtained from nihroadmap.nih.gov Iclinicalresearchl ov erview-ttranslational.asp. ObiecliVes Discuss the relevance of nursing time in the context of the current health care environment. Discuss the meaning of time in the context of physics, psychology, &. sociology. Discuss the meaning of the term nursing as currently used. Describe a holistic framework for the concept nursing time. Identify the implications for theory, practice, &. research. Our Heallhcare.IOM 2000 Svslem Jodav -To Err Is Human: Building a Safer Health System -98,000 hospitalized Americans die each year as a result of errors in their care.iom Crossing the Quality Chasm: A New Health System for the 21st Century -Health care harms patients too frequently and routinely fails to deliver its potential benefits -Workforce issues significant.iom Keeping Patients Safe: Transforming the Work Environment of Nurses -2.8 million nurses -2.3 million nurse assistants -Represent >54% otall health care providers in the US -The provider patients are most likely to encounter - Theprovider patients will spend the most time with -The provider most likely to intercept errors before they reach patients (86% medications intercepted) - Theprovider that is indispensable to patient safety Conventional Approach Hospital HPPD -: :: Experience FTEs Ratios ~Education Surveillance Mortality Complications Burnout/Satisfaction

2 Are we measuring what is important or simply making important what we can measure? (Wiener 2004) - ~."., ~... ~.( I New Strategy Hospital +Unit+Patient ~?\ ~~ IOrganizationai "Budget policy priorities ~-ariab!e-s i're~ource :l!location i:~~i:~::;~=::ure IPalienl\"a.riablcs 'l~ &~('\...nt;:of;:u""" Co-moroidi!;~ & (;sk Ucto<. Xl1mb.,ofh<-olwprobl""", ')!Wica] t<utm""t pbn 1'~CUf"U""0.1 p-~ci."t ;,dition ~"- h.e ~"-..",1 ' ~~~ --...Outcomes Adequate.... PatIent r ~ Nurse Skill, Of'.. I~terventions -/ Patient 1 ImPlementatio~ _:;;mplemented Nurse -<-. X /" Contextual Factors Philosophy of care opriority ~ehiog 'CuJtucc\'a!ues ~ur.;jngcare st:lil.hrds Local& national 'delines, procedures "Schubert er al 200i Conceptual framework: Implicit rarioning of nursing care ~Ur<C<.)UICOn\C1 The Dual Role of Nurses -Professional Provider -Employee Care< llme [1 D >Money Nurse-Patient Relationship Individualized Patient-Centered Care Legal obligation to protect patients BON (Duty to Patients) Goal is quality health care Work Assignment Effidency & Standardization Employee obligations Managers (Duty to employer) Goal is profit marain Quality Ah Cost 2

3 How shou/dnurses spend their time??? How are nurses spending their time??? What are the consequences of nursing time allocation decisions??? What is the right amount of nursing time for individual families??? (S) \ How much nursing, time patients shouldwe and allocate??? How much nursing time can we afford??? Deconstructing.../ Q' Nursing Metaphysics - is measured Psychology - is experienced Sociology - is negotiated 3

4 Phvsical PSVchological 0 T, ~~ "~' Events n I I Instants ~ ~ ~ ~ Duration I Temporality & Sequence Past, Present, Future Dura'tion IY Objective Duration Fixed Non-elastic Shared Subjective Variable Elastic Personal Sociologic Coordination of interdependent actions through Negotiated Temporal Structures Subjective Variable Elastic Shared Structures - Patterns of behavior created and used by people to give rhythm and form to their everyday work practices. - They serve the purpose of guiding, orienting, and coordinating ongoing interdependent activities and shape how people approach work tasks. - Result in an inter-subjective experience & establishment of normative organizational behavior & routines Structures Human ~ said -Human to shape actionand is Action '''uctu"" be shaped by time 't"'ctu",,~ ~ ~ "'uctun" Human Action -Function to constrain or enable social actions 4

5 Perception is RealilV! No we can't! Constraining Yes we can! Enabling t'~ ~. structures can be multiple, simultaneous, competing & interdependent Managing & Changing Structures PsVchological Response to Structures management Collective time coordination Individual problem/focus Group problem/focus Pressure Poverty Famine Temporal Shins Speaks Changing temporal structures changes the experience of time - Dimensions Sense of time pressure Sense of found time Perceived discretion over time Perceived tension among competing task demands Planning time horizon Semiotic codes that communicate social messages Dimensions of time have symbolic meaning - Duration - Frequency - Timing - Speed 5

6 Perception is RealilV! No we can't! Constraining Yes we can! Enabling t'~ ~. structures can be multiple, simultaneous, competing & interdependent Managing & Changing Structures PsVchological Response to Structures management Collective time coordination Individual problem/focus Group problem/focus Pressure Poverty Famine Temporal Shins Speaks Changing temporal structures changes the experience of time - Dimensions Sense of time pressure Sense of found time Perceived discretion over time Perceived tension among competing task demands Planning time horizon Semiotic codes that communicate social messages Dimensions of time have symbolic meaning - Duration - Frequency - Timing - Speed 5

7 Speaks Messages conveyed through time dimensions - Value - Commitment - Intimacy - Respect - Formality \C1.G'\ - Accessibility. ~\). [rj ]) Examples 01 Language We spend more time on activities we value and on relationships to which we are committed People kept waiting feel devalued Being on time is a sign of respect Some places & times are socially defined as more privateinteractions in this context convey intimacy Examples 01 the Language An open door policy communicates commitment & importance Definitive plans convey message of relative importance - Let's have lunch tomorrow - Let's get together sometime Spontaneous interactions may be seen to reflect more informal/intimate relationships Actions completed hurriedly can communicate business or disinterest Nursing Nursing Nightingale (1859) - Managers of the environment for the purpose of promoting health and preventing complications - Roles Direct physical care Teaching Emotional support Surveillance Supervision Nursing Fawcett (1984) - Nursing Meta-paradigm Nursing Person Environment Health ANA (2003) - Social policy statement/definition 6

8 The question "what is nursing" subsumes the question "how do nurses interact with patients and the environment to achieve a state of well being for persons". Knowledge of what nurses do and how they do it is essential to understanding the meaning of nursing. The nursing process continues to be the mechanism through which nurses interact with patients and the environment - it constitutes the "how" of nursing. The Role 01 Nursing - What Nurses Do Available interventions Environment of care Scientific evidence Available technology Nursing theory & philosophy Ethical & community standards Institutional policy Legally defined scope of practice Nursing Roles Direct physical care - Teaching - Emotional support - Surveillance - Supervision - Coordination The work/activities Vs The work/activities of Nurses of Nursing 7

9 He-Constructing Nursing k\ Environment of Providers and Recipients of Nursing Care, '" ~~ Nursing Physical Psychological Sociological Qualitative measures Ratios Self-report HPPD FTEs An interval measured by a clock during which nursing care and other workrelated activities are performed or supervised by nurses Experienced by providers & recipients of nursing care through perception Surveys Focus groups Direct care time Subjective instruments Experienced by providers & recipients of nursing care through shared temporal structures is Measured Ordered sequencing of events Duration of events Quantitative comparisons is Experienced signment of meaning to events Sense of time quality pressure poverty/famine Established work shifts discretion Standardized medication times Standardized procedure sequences Hours of operation for ancillary departments is Negotiated Coordination of interdependent actions/activities Turbulence waste Found time rationing/missed care 8

10 The Ethics of Nursing Beckstrand (1978) - Goal of practice discipline is to bring about changes in entities such that a greater degree of defined good (value) is realized - Establishes the moral obligation of nurses toward patients - Establishes standard for evaluating the relative goodness/badness of people & things Intrinsic - good in & of itself Instrumental- lead to good outcome Braddock & Snvder (2005) has intrinsic & instrumental value in medicine Distinguished between time as quantity & time as quality Perceived quality of time is fundamental to the patient experience - Quality time = Adequate time - Sufficient time to meet professional & ethical obligations with patients Braddock & Snvder (2005) as quantity is necessary for time as quality (adequate time) Adequate time is necessary to promote trust & patient-centered communication Trust & patient-centered communication are inherent to strong therapeutic relationships Strong therapeutic relationships lead to good outcomes (as quantity & quality) has intrinsic and instrumental value Conclusions & Implications Nursing time has significant intrinsic & instrumental value in nursing and healthcare All three dimensions of time should be included in our conceptualization of nursing time Better measures of organizational & nursing performance are needed to guide staffing decisions (move beyond physical time & embrace qualitative measures) Multiple strategies to enhance the patient experience of nursing time are warranted and should address how much time nurses spend with patients as well as how they spend that time Practicing nurses should be cognizant of the semiotics of nursing time 9

11 Conclusions & Implications More theory development & empirical research is needed to examine relationships between sociological, physical, and psychological nursing time Strategies to more evenly distribute the demand for nursing time across a shift should be explored structures Patterns offor overlapping nurses should & competing be identified time and evaluated for their effect on nursing & patient outcomes How nurses prioritize when faced with overlapping time demands warrants further exploration Practicing nurses & nurse manaqers should be empowered to change existing time structures when sub-optimal coordination - emphasize collective time Thanks for Sharing Your with Me! 10