Post on 29-Mar-2019
Clinical Scholarship: Caring, Questioning, and
Owning the Outcomes
Kristen M. Swanson, RN, PhD, FAAN
broken rules,
mistakes,
lack of support,
incompetence,
poor teamwork,
disrespect,
micromanagement.
where 7 weapons of silence ….
sacrifice safety
(2005)
harm patients,
fracture families,
ruin careers,
increase legal costs,
bankrupt organizations,
skyrocket costs
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
Reshaping Healthcare
OPTIMAL
HEALING ENVIRONMENT
Mission-driven
CARING
ORGANIZATION Care System
Family
Patient
Providers Employees
Respect
It takes an organization that mandates…..
Clearly articulated, universally embraced commitment to caring for patients, families, employees, community Learning environment with non-punitive responses to errors Servant leadership – from the C.E.O. all the way up to the point of care Infrastructures and policies that fully support a caring, safety, and patient-focused mission
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
Process Product
Qualitative Inquiry Middle Range Theory
Description Measurement
Randomized Control Clinical Trials
Efficacy
Participatory Action Research
Community based intervention
Translation Application Effectiveness
From Research
to Practice
Swanson Caring Theory
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 emotionally
present to the other
Being with
being there
conveying availability
enduring with
sharing feelings
not burdening
doing for the other as they
would do for themselves if
it were at all possible
Doing For
performing competently / skillfully
comforting
anticipating
protecting
preserving dignity
informing / explaining
validating / giving feedback
supporting / allowing / focusing
generating alternatives
thinking it through
Enabling
facilitating the other’s
passage through life
events and transitions
Maintaining Belief
believing in / holding in esteem
offering a hope-filled attitude
‘going the distance’
offering realistic optimism
helping find meaning
sustaining faith in the other’s
capacity to get through an event
or transition and face a future
with meaning
Knowing Doing for
Being with: being emotionally present to
the other.
Knowing: striving to understand an event as it has
meaning in the life of the other. Doing for: doing for others as they would do for
themselves if were at all possible.
Enabling: facilitating the other’s passage
through events or transition by providing support, information, and validation.
Maintaining belief: sustaining faith in the
other’s capacity to come through events or transitions and face a future with meaning.
Recipient’s feeling
Enabling Being with
Maintaining belief CARING
healing
valued
understood
safe and comforted
capable
healing understood valued safe and
comforted capable hopeful
Caring is a nurturing way of relating to
a valued other toward whom one feels a personal sense of commitment and responsibility.
Swanson Caring Theory
hopeful
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
Positive Informative Clinically competent An attentive listener Centered on you Technically skilled Respectful of you
Comforting Understanding Personal Caring Supportive Aware of your feelings Visibly touched by your experience Able to offer you hope
Competent Practitioner
Compassionate Healer
Was the (provider) who just took care of you?
1 = no, not at all
5 = yes, very much
What is it really like to provide care in a
complex context?
caring avoiding bad outcomes
attaching
managing responsibilities
Are you getting too attached?
REALLY????
How are you monitoring your caring effectiveness?
ALOOF DETACHED ENGAGED ENMESHED
Therapeutic Zone
B
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C
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P
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S
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F
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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: Application
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
Theory Development: Translation to Practice
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 CareTM
Tonges M, Ray J.
Translating caring theory into practice: the Carolina Care Model.
J Nurs Adm. 2011 Sep;41(9):374-81
Carolina CareTM
Behaviors and Associated
Swanson Caring Theory Component
• Each patient each shift
• Nurse sits with patient
• 3-5 minutes of touch and therapeutic listening
Moment of Caring: Knowing
and Being with
Carolina CareTM
Behaviors and Associated
Swanson Caring Theory Component
• Answer call lights regardless of assignment
• “Road Signs” posted in hallways
No Passing Zone: Being
with and Doing For
Carolina CareTM
Behaviors and Associated
Swanson Caring Theory Component
• Alternative to “scripting”
• Key points to cover in interactions
Words and Ways
that Work: Being
with and Enabling
Carolina CareTM
Behaviors and Associated
Swanson Caring Theory Component
• Listen to patient
• Apologize without placing blame
• Take action to address problem
• Follow-up with patient
Blameless Apology:
Being with and Enabling
Hourly Patient Rounds
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)
R
O
U
N
D
S
Associated
Swanson Caring
Theory
Processes:
Being With and
Doing For
83 83 83.3 83.2
83.7
85
86.5 86.1
87.6 88
86.8 87 87.2 87.1 87.3
88.7
90.4 89.9
91.2 91.5
78
80
82
84
86
88
90
92
94
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Overall Nursing
Figure 4. Annual Mean PG Scores for Overall Satisfaction and Satisfaction with Nursing 2004-2013
Carolina Care in July
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.
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.