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…

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

Change is happening…

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

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 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

Caring in a Complex Context

caring

managing responsibilities

attaching

avoiding bad outcomes

Are you getting too attached?

REALLY????

How are you monitoring your caring effectiveness?

ALOOF DETACHED ENGAGED ENMESHED

Therapeutic Zone

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Impact

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

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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

Carolina CareTM and prevalence of nosocomial ulcers

Pressure Ulcer Prevalence Mar 2004 – May 2010

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