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TRANSLATING CARING THEORY INTO PRACTICE
Session C631ANCC National Magnet Conference
October 5, 20112:45-3:45 PM
Kristen Swanson PhD, RN, FAANUNC –Chapel Hill School of Nursing
Chapel Hill, NC
Mary Tonges, PhD, RN, FAANUNC HospitalsChapel Hill, NC
Translating Caring Theory into Practice
Swanson Caring Theory
Carolina CareTM: A Translational Model
Theory – Practice Links
Developing, Implementing, and Sustaining
Results
g pThe Carolina Nursing Partnership:
Closing the Practice and Education Gap
The Carolina Nursing Partnership: Closing the Practice-Education Gap
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UNC Hospitals andHealth 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-CHSchool 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)
The Carolina Nursing
Partnership: Closing the
Practice-Education Gap
• Starts at the top: commitment to ‘get this partnership right’
• Sustained through dialogue and visibility
• Leveraged through joint successes (i.e., Carolina CareTM 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!!!
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OPTIMALHEALING
ENVIRONMENT
Mission‐driven
CARINGORGANIZATION
UNC Health Care System
Family
Patient
EmployeesProviders
It takes an organization that mandates…..
Clearly articulated, universally embraced commitment to caring for patients, families, employees, communityLearning environment with non‐punitive responses to errors Servant leadership – from the C.E.O. all the way up to the point of careInfrastructures 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
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is a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility
Swanson, KM 1991, Empirical development of a middle range-theory of nursing, Nursing Research, 40(3) 161-6.
Caring• Knowing• Being with• Doing for• Enabling• Maintaining Belief
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 there• conveying availability• enduring with • sharing feelings• not burdening
being emotionally present to the other
Being With
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• performing competently / skillfully
• comforting• anticipating• protecting• preserving dignity
doing for the other as they would do for their self if it were at all possible
Doing For
facilitating the other’s passage through life events and transitions
Enabling • informing / explaining • validating / giving feedback• supporting / allowing• focusing • generating alternatives /
thinking it through
sustaining faith in the other’s capacity to get through an event or transition and face a future with meaning
Maintaining Belief
• believing in / holding in esteem• offering a hope-filled attitude• ‘going the distance’• offering realistic optimism• helping find meaning
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Knowing Doing for
Kristen M. Swanson, RN, PhD, FAAN
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
EnablingBeing with
Maintaining beliefCARING
healing
valued
understood
safe and comforted
capable
healingunderstoodvaluedsafe and comfortedcapablehopeful
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
willing to own that in every interaction they are the ‘face, hands, head, and heart of the mission.’
It takes people who are…..
“Giving Exceptional Service: Everyone, Every time, Everywhere”
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
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Multi-Level Rounding
Interdisciplinary
DirectorHourly Patient Rounding
Health Unit Coordinator
(HUC)
Nurse Manager
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 Component:
Being With and Doing For
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
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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
Swanson Caring Theory: Framing the Culture of Carolina CareTM
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Proposed Links Between Carolina CareTM
Interventions and Swanson Caring Theory Processes
Swanson Caring Theory Processes
Carolina Care
TMInterventio
ns
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 3rd place in the U.S. News & World Report rankings using HCAHPS Satisfaction with Nursing Care
• Press Ganey Patient Satisfaction Scores historically holding around the 40th percentile
Challenge
• CEO charged CNO to raise PG scores to 65thpercentile by end of 4thquarter of CY 09
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Pilot Project
Model Units: Medicine & Surgery Service• Less than 20 beds• Combination of private/semi‐private rooms
CNO chaired Carolina CareTM 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
0102030405060708090100
BaselineN=34
Q1 2009N=49
4/3N=38
4/17N=47
5/1N=55
5/15N=59
5/29N=65
Courtesy of person served food
Courtesy of person cleaning room
Accommodations and comfort visitors
Staff include decisions re:trtmnt
Percen
tile
Data Driven Action Plan Areas
Discharge Week
Implementation of Carolina CareTM
020406080100120
BaselineN=34
Q1 2009N=49
4/3N=38
4/17N=47
5/1N=55
5/15N=59
5/29N=65
Promptness response to call
Staff addressed emotional needs
Response concerns/complaints
Discharge Week
Implementation of Carolina CareTM
Model Unit Results
Percentile
Priority Trends
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Preparation for Full Implementation
Published Carolina CareTM Guidebook– CNO charge– Lessons learned from Model Units– Defined key staff roles and responsibilities– Pre‐Work– Implementation sequence– Defined Carolina CareTM Interventions
• Moment of Caring• Hourly Rounds• No Passing Zone• Words and Ways that Work• Blameless Apology (Service Recovery)
Carolina CareTM Pre-Work : Unit Assessment
Patient satisfaction interviewPart I
Self assessmentPart II
Part III Analyze one year of unit performance on Press Ganey data
Call bell activityPart IV
Environmental assessment Part V
Carolina CareTM Pre-work: Establish Teams
Nursing Teams
• Nurses• Nurses Assistants• Health Unit Coordinators
Interdisciplinary Teams
• Nurses• Housekeeping• Nutrition & Food Service
• Plant Engineering• Other Support Services
Action Plans
• Assign process owners accountability for specific items
• Team approves action plan
Unit Implementation Led by Nurse Mangers
• Nurse Manager held accountable for improving inpatient satisfaction at the unit level
Carolina CareTM Implementation Oversight Committee
• CNO• Nursing Directors• Nurse Managers
• Director, Environmental Services• Director, Food and Nutrition• Data Analyst
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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
“Carolina CareTM Dollars”“Carolina CareTM Dollars”
Unit recognition for Press Ganeygoals achievementUnit recognition for Press Ganeygoals achievement
Unit CelebrationsUnit Celebrations
Results: Annual Mean PG ScoresOverall Inpatient Satisfaction and Satisfaction with Nursing
Carolina CareTM
implemented in July
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Results: Mean PG ScoresConcern with Privacy, Meeting Emotional Needs and
Special Attention to Special/Personal Needs
74
76
78
80
82
84
86
88
90
2004 2005 2006 2007 2008 2009 2010 2011
Concern for privacy Meeting emotional needs Attention to special/personal needs
Carolina CareTM
implemented in July
Results: Mean PG Scores Satisfaction with Pain Control and Prompt Response to Call
82
83
84
85
86
87
88
89
2004 2005 2006 2007 2008 2009 2010 2011
Pain controlled Prompt response to call
Carolina CareTM
implemented in July
Hospital Consumer Assessment of Healthcare Provider Systems (HCAHPS)Hospital Discharges July 2009‐June 2010 (335 Response)
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Carolina CareTM and prevalence of nosocomial ulcers
Pressure Ulcer Prevalence Mar 2004 – May 2010
Carolina CareTM Oversight Committee –Next Steps
Expansion
• Critical Care• Surgical Services• Ambulatory Services
• Pastoral Services
Outcomes Dashboard
• Pressure Ulcers• Falls• Restraints• Catheter associated urinary tract infections
NewInterventions
• Semi‐Private Rooms
• Carolina CareTM
at Home
Translating Caring Theory into Practice
Carolina CareTM
Transformational Leadership
Structural Empowerment
Exemplary Professional Practice
New Knowledge, Innovations & Improvements
Tonges M, Ray J. Translating caring theory into practice: the Carolina CareTM
Model. J Nurs Adm. 2011; 41(9): in press.
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Contact Information
Kristen Swanson PhD, RN, FAANUNC–Chapel Hill School of Nursing
Mary Tonges, PhD, RN, FAANUNC Hospitals