TRANSLATING CARINGTHEORY INTO PRACTICE Session C631 ANCC National Magnet Conference October 5, 2011 2:45-3:45 PM Kristen Swanson PhD, RN, FAAN UNC Chapel Hill School of Nursing Chapel Hill, NC Mary Tonges, PhD, RN, FAAN UNC Hospitals Chapel Hill, NC Translating Caring Theory into Practice The Carolina Nursing Partnership: Closing the Practice and Education Gap Swanson Caring Theory : A Translational Model Theory Practice Links Developing, Implementing, and Sustaining Results The Carolina Nursing Partnership: Closing the Practice-Education Gap 1
UNC Hospitals and Health Care System Public Academic Health Care Center North Carolina s safety net hospital Full service -- fetal surgery to hospice 804 inpatient beds 8000 employees 1100 attending physicians 6 Specialties in top 50 USNWR rankings Cleverly top 100 community value hospitals UNC-CH School of Nursing US News and World Report ranked # 4 NIH Ranked # 18 Admit 154 BSN / ABSNs per year graduation rate = 96%; on time = 91% NCLEX first time pass rate = 98% MSN grads = approx 75 per year PhD grads = 5 to 12 per year Faculty = 43 tenure line; 74 fixed term Two T-T32s: Chronic Illness and Health Care Systems Home of QSEN (Cronenwett and Sherwood) RWJF ENF Co-Director (Cronenwett) Starts at the top: commitment to get this partnership right The Carolina Nursing Partnership: Closing the Practice-Education Gap Sustained through dialogue and visibility Leveraged through joint successes (i.e., with Swanson Caring Theory) Publicized by calling attention to each other s accomplishments Funded through in kind connections, contracted partnerships (teaching, practice, and research), and joint fund raising Benefits priceless!!! 2
OPTIMAL CARING UNC Health Care System HEALING ORGANIZATION ENVIRONMENT Family Patient Providers Employees Mission driven It takes an organization that mandates.. Clearly Learning Infrastructures Servant articulated, leadership environment and universally from policies withthe non punitive that embraced C.E.O. fully all support the commitment responses way a caring, up to to errors the safety, caring point and for of patient focused patients, care families, mission employees, community Begin with your very notion of what it means to have personhood. Then accord every individual you meet with the status of personhood under that condition your capacity for caring will become easy to access. Jean Watson 3
Caring is a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility Knowing Being with Doing for Enabling Maintaining Belief Swanson, KM 1991, Empirical development of a middle range-theory of nursing, Nursing Research, 40(3) 161-6. striving to understand an event as it has meaning in the life of the other Knowing avoiding assumptions assessing thoroughly seeking cues centering on the other engaging the self of both Being With being emotionally present to the other being there conveying availability enduring with sharing feelings not burdening 4
Doing For doing for the other as they would do for their self if it were at all possible performing competently / skillfully comforting anticipating protecting preserving dignity facilitating the other s passage through life events and transitions Enabling informing / explaining validating / giving feedback supporting / allowing focusing generating alternatives / thinking it through Maintaining Belief sustaining faith in the other s capacity to get through an event or transition and face a future with meaning believing in / holding in esteem offering a hope-filled attitude going the distance offering realistic optimism helping find meaning 5
Being Knowing: Enabling: Caring is facilitating a nurturing striving to understand the other s way of passage relating to Doing Maintaining an event as it has with: for: doing being belief: for emotionally others sustaining as they present faith would in to the do for a valued meaning through other events toward themselves in the life or transition whom of the other. by providing one feels a other s support, capacity information, other. if were to come at all and possible. through events personal Swanson validation. or transitions sense of and commitment Caring Theory face a future with and meaning. responsibility. Being with Enabling Maintaining CARINGbelief healing Recipient s feeling capable valued understood safe healing capable hopeful valued and comforted Knowing Doing for understood safe and comforted Kristen M. Swanson, RN, PhD, FAAN It takes people who are.. willing to own that in every interaction they are the face, hands, head, and heart of the mission. Giving Exceptional Service: Everyone, Every time, Everywhere Behaviors and Associated Swanson Caring Theory Component Moment of Caring: Knowing and Being with Each patient each shift Nurse sits with patient 3 5 minutes of touch and therapeutic listening 6
Multi-Level Rounding Nurse Manager Health Unit Coordinator (HUC) Interdisciplinary Hourly Patient Rounding Director Hourly Patient Rounds R O U N D S Are you comfortable? Other Side (Does patient need to turn?) Use the bathroom (Does patient need assistance?) Need anything Door/curtain open or closed for privacy Safety (Call bell will reach and no tripping hazards) Associated Swanson Caring Theory Component: Being With and Doing For Behaviors and Associated Swanson Caring Theory Component No Passing Zone: Being with and Doing For Answer call lights regardless of assignment Road Signs posted in hallways 7
Behaviors and Associated Swanson Caring Theory Component Words and Ways that Work: Being with and Enabling Alternative to scripting Key points to cover in interactions Behaviors and Associated Swanson Caring Theory Component Blameless Apology: Being with and Enabling Listen to patient Apologize without placing blame Take action to address problem Follow up with patient Swanson Caring Theory: Framing the Culture of 8
Proposed Links Between Interventions and Swanson Caring Theory Processes Interventions Swanson Caring Theory Processes Knowing Being With Doing For Enabling Moment of Caring Hourly Rounds No Passing Zone Words & Ways that Work Blameless Apology Developing, Implementing, and Sustaining Patient Satisfaction: The Disconnect and the Challenge Disconnect UNCH tied for 3 rd place in the U.S. News & World Report rankings using HCAHPS Satisfaction with Nursing Care Press Ganey Patient Satisfaction Scores historically holding around the 40 th percentile Challenge CEO charged CNO to raise PG scores to 65 th percentile by end of 4 th quarter of CY 09 9
Pilot Project Model Units: Medicine & Surgery Service Less than 20 beds Combination of private/semi private rooms CNO chaired Carolina Care TM Steering Committee to provide high level direction, integration and support Voice of the Patient Rapid Cycle Improvement: Design & Implement Nursing & Multidisciplinary Unit Based Teams Data Driven Action Plans/Performance Tracking Model Unit Results Data Driven Action Plan Areas Percentile 100 90 80 70 60 50 40 30 20 10 0 Baseline N=34 Q1 2009 N=49 4/3 N=38 Implementation of 4/17 N=47 Discharge Week 5/1 N=55 5/15 N=59 5/29 N=65 Courtesy of person served food Courtesy of person cleaning room Accommodations and comfort visitors Staff include decisions re:trtmnt Model Unit Results Percentile 120 100 80 60 40 20 0 Baseline Q1 2009 N=34 N=49 Priority Trends 4/3 N=38 4/17 N=47 5/1 N=55 5/15 N=59 5/29 N=65 Discharge Week Promptness response to call Implementation of Staff addressed emotional needs Response concerns/complaints 10
Preparation for Full Implementation Published Guidebook CNO charge Lessons learned from Model Units Defined key staff roles and responsibilities Pre Work Implementation sequence Defined Interventions Moment of Caring Hourly Rounds No Passing Zone Words and Ways that Work Blameless Apology (Service Recovery) Pre-Work : Unit Assessment Part I Part II Patient satisfaction interview Self assessment Part III Part IV Analyze one year of unit performance on Press Ganey data Call bell activity Part V Environmental assessment Pre-work: Establish Teams Implementation Oversight Committee CNO Nursing Directors Nurse Managers Director, Environmental Services Director, Food and Nutrition Data Analyst Nursing Teams Interdisciplinary Teams Action Plans Unit Implementation Led by Nurse Mangers Nurses Nurses Assistants Health Unit Coordinators Nurses Housekeeping Nutrition & Food Service Plant Engineering Other Support Services Assign process owners accountability for specific items Team approves action plan Nurse Manager held accountable for improving inpatient satisfaction at the unit level 11
Simultaneous roll out on all acute care units 8 Week Implementation Sequence Monday morning Nurse Mangers meeting Weekly focus areas Rounding Words & Ways that Work Bi weekly nursing & Interdisciplinary team meetings Building action plans Tracking performance measures Daily huddles Bright Ideas Implementation Oversight Committee Recognizing Outstanding Performers Dollars Unit recognition for Press Ganey goals achievement Unit Celebrations Results: Annual Mean PG Scores Overall Inpatient Satisfaction and Satisfaction with Nursing implemented in July 12
Results: Mean PG Scores Concern with Privacy, Meeting Emotional Needs and Special Attention to Special/Personal Needs 90 Concern for privacy Meeting emotional needs Attention to special/personal needs 88 86 84 82 80 78 76 74 2004 2005 2006 2007 2008 2009 2010 2011 implemented in July Results: Mean PG Scores Satisfaction with Pain Control and Prompt Response to Call 89 88 87 86 85 84 83 Pain controlled Prompt response to call 82 2004 2005 2006 2007 2008 2009 2010 2011 implemented in July Hospital Consumer Assessment of Healthcare Provider Systems (HCAHPS) Hospital Discharges July 2009 June 2010 (335 Response) 13
Pressure Ulcer Prevalence Mar 2004 May 2010 and prevalence of nosocomial ulcers Oversight Committee Next Steps Expansion Critical Care Surgical Services Ambulatory Services Pastoral Services Outcomes Dashboard Pressure Ulcers Falls Restraints Catheter associated urinary tract infections New Interventions Semi Private Rooms at Home Translating Caring Theory into Practice Structural Empowerment Exemplary Professional Practice Transformational Leadership Carolina Care TM New Knowledge, Innovations & Improvements Tonges M, Ray J. Translating caring theory into practice: the Model. J Nurs Adm. 2011; 41(9): in press. 14
Contact Information Kristen Swanson PhD, RN, FAAN UNC Chapel Hill School of Nursing swanson@email.unc.edu Mary Tonges, PhD, RN, FAAN UNC Hospitals mtonges@unch.unc.edu 15