Clinical Scholarship: Caring, Questioning, and Owning the Outcomes Kristen M. Swanson, RN, PhD, FAAN
Premise: Providing better healthcare for more people at a lower cost is a universal challenge
In health care for too long we have tolerated toxic work environments
where 7 weapons of silence. broken rules, harm patients, mistakes, fracture families, lack of support, ruin careers, incompetence, increase poor teamwork, legal costs, bankrupt organizations, disrespect, micromanagement. skyrocket costs (2005) sacrifice safety
Change is happening
Reshaping Healthcare 1. Continuous healing relationships 2. Driven by patient s needs and values 3. Patient controls 4. Shared knowledge, communication 5. Evidence-based decision making 6. Safety as a system property 7. Transparency 8. Anticipation of needs 9. Continuous decrease in waste 10. Cooperation among clinicians www.premierinc.com
CARING ORGANIZATION Care System OPTIMAL HEALING ENVIRONMENT Family Patient Providers Employees Respect Mission-driven
It takes an organization that mandates.. Clearly Learning Servant Infrastructures articulated, leadership environment and universally policies from with the 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
Swanson Caring Theory From Research to Practice Process Qualitative Inquiry Description Randomized Control Clinical Trials Participatory Action Research Translation Product Middle Range Theory Measurement Efficacy Community based intervention Application Effectiveness
Middle Range Theory of caring Knowing Being with Doing for Enabling Maintaining Belief
Knowing striving to understand an event as it has meaning in the life of the other 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
Doing For doing for the other as they would do for themselves if it were at all possible performing competently / skillfully comforting anticipating protecting preserving dignity
Enabling facilitating the other s passage through life events and transitions 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
Caring a nurturing way of relating to Enabling:isfacilitating the other s passage Knowing: striving toemotionally understand an event as itfor has Maintaining belief: sustaining faith intothe Doing for: doing for others as they would do Being with: being present a valued other toward whom one feels a through events or transition by providing meaning in the life of the other. other s capacity to come through events themselves if were at all possible. the other. Swanson Caring Theory support, information, and validation. personal sense of or transitions andcommitment face a future withand meaning. responsibility. Being with healing Recipient s feeling capable Enabling valued Maintaining CARINGbelief safe and understood healing capable hopeful valued comforted understood Knowing Doing for safe and comforted
What are the most preferred nurse caring behaviors? 517 nurses (10 studies) & 305 patients (8 studies)
Most preferred nurse caring behaviors nurses - top 5 listens to the patient (100%) allows expression of feelings (90%) uses touch to comfort (76%) perceives pt. s needs (71%) realizes pt. knows self best (64%) patients - top 5 provides adequate care (100%) give shots/manage equipment (93%) gets to know pt. as a person (88%) puts pt. first no matter what (69%) treats me with respect (68%)
Five Modes of Being in Relationship* 1. Bio-genic life giving fosters spiritual freedom, healing flows freely (SELF AND OTHER = INSPIRING CO-CREATORS) 2. Bio-active life sustaining concerned, compassionate, competent (SELF AND OTHER = CARING PARTNERS) 3. Bio-passive life neutral detached, passive, disengaged (SELF AND OTHER = IRRELEVANT) 4. Bio-static life restraining blind to the other s plight, neglect them as a nuisance (SELF = ENTITLED; OTHER = IRRITANT) 5. Bio-cidic life destroying acid-edged, alienating, diminishing the other (SELF = PERPETRATOR; OTHER = TARGET) * Halldorsdottir, 1991
Was the (provider) who just took care of you? Competent Practitioner Positive Informative Clinically competent An attentive listener Centered on you Technically skilled Respectful of you Compassionate Healer Comforting Understanding Personal Caring Supportive Aware of your feelings Visibly touched by your experience Able to offer you hope 1 = no, not at all 5 = yes, very much
What is it really like to provide care in a complex context? managing responsibilities caring avoiding bad outcomes attaching
Caring in a Complex Context managing responsibilities caring avoiding bad outcomes attaching
B U R N O U T How are you monitoring your caring effectiveness? Are you getting too attached? ALOOF DETACHED ENGAGED ENMESHED REALLY???? Therapeutic Zone C O M P A S S I O N F A T I G U E
Impact
Theory Development: Application Kavanaugh: consenting vulnerable populations Compton, McDonald, Stetz: bone marrow transplantation Zerwekh: disenfranchised people Ryden: dementia and alzheimer's Nelson-Peterson: practice environment and lean Adolfsson: miscarriage Johnston: intimate partner violence Roscigno: children with TBI Tonges and Ray: practice outcomes Wands: wounded veterans Glembocki: educating a caring culture Leadbeater: student perspective O Connell: mental health inpatient Andersen: midwifery clinic Beatty: high risk families Kish and Holder: support group perinatal loss
Theory Development: Translation to Practice Ongoing since 1990 s Abbott-Northwestern Hospital Relationship Based Care, Koloroutis Magnet Emphasis Caring / Lean: Virginia Mason Medical Ctr., Seattle Children s, Swedish Health System Caring and Organizational Change Organizational Impact: UNC Hospitals
TRANSLATING CARING THEORY INTO PRACTICE UNC Health Care Joint Conference and Quality Committee Kristen M. Swanson PhD, RN, FAAN Dean UNC-Chapel Hill School of Nursing Mary Tonges, PhD, RN, FAAN Senior Vice President and Chief Nursing Officer, UNCH
Swanson Caring Theory: Framing the Culture of Carolina Care TM Tonges M, Ray J. Translating caring theory into practice: the Carolina Care Model. J Nurs Adm. 2011 Sep;41(9):374-81
Carolina Care TM 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
Carolina Care TM 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
Carolina Care TM 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
Carolina Care TM 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
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 Processes: Being With and Doing For
94 92 91.2 91.5 90 90.4 89.9 88 86 86.8 87 87.2 87.1 87.3 85 88.7 86.5 86.1 87.6 88 84 83 83 83.3 83.2 83.7 82 80 78 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Overall Nursing Carolina Care in July Figure 4. Annual Mean PG Scores for Overall Satisfaction and Satisfaction with Nursing 2004-2013
Pressure Ulcer Prevalence Mar 2004 May 2010 Carolina Care TM and prevalence of nosocomial ulcers
Leadership
"A leader is anyone who wants to make a difference at this time in this place." Margaret Wheatley
Compassion Knowing: Strive to understand the mission; identify capacities of staff, colleagues, and learners; and continually seek to know the needs of those we serve. Being with: Stay present to the losses, challenges, setbacks, successes, and joys experienced by staff, colleagues, learners, and the community that surrounds us.
Competence Doing For: Create and sustain a culture of safety, respect, and comfort. Use your position to advocate for others when they are unable to so for themselves. Standardize practice based on best evidence. Enabling: Facilitate innovation and collaboration; Invest in people, ideas, and the future by supporting diversity in thought, a learning environment, sharing responsibility for leadership, collaborating with colleagues, and leveraging academic-practice partnerships, and engaging with the community.
Creativity Maintaining Belief sustain a sense of hope, take pride in accomplishments, challenge the way it has always been, take risks, continuously improve, stay in touch with the world around us, become invaluable to our neighbors, serve with integrity, and leave the organization better than you found it.
Finding Joy and Meaning in the Service of Others
This is my depressed stance. When you re depressed, it makes a lot of difference how you stand. The worst thing you can do is straighten up and hold your head high because then you ll start to feel better. If you re going to get any joy out of being depressed, you ve got to stand like this. Charlie Brown
Joy-full-ness 1. Knowing you are exactly where you are meant to be. 2. Affirming life through service, creation, and connection. 3. Being intimately connected to people, purpose, and place. 4. Experiencing the awesomeness of living the life that is yours. 5. Realizing grace: living with faith, hope, and love.
One can never consent to creep when one feels an impulse to soar. Helen Keller
PLEASE DO NOT COPY, QUOTE, OR DISSEMINATE WITHOUT WRITTEN PERMISSION from Kristen M. Swanson, RN, PhD, FAAN Dean and Professor Swansonk@seattleu.edu