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http://www.standarderrors.org/Presentations/ISPN2004.PPT
Unitary Appreciative Inquiry: Praxiological Investigation of Risk Induced Professional
Caregiver Despair: Reflections and Implications
Thomas Cox RN, BA, BSN, MS, MSW, MSDoctoral Candidate
School of Nursing
Virginia Commonwealth University
International Society of Psychiatric Mental Health Nurse
St. Louis, Missouri
April 30, 2004
http://www.standarderrors.org/Presentations/ISPN2004.PPT
Who am I & What Will I Cover Today?
Psychiatric NursePsychiatric Social Worker
StatisticianMathematician
Insurance ProfessionalResearcher
Doctoral Candidate
Professional Caregiver Insurance RiskUnitary Appreciative Inquiry
Risk Induced Professional Caregiver Despair
Questions - Answers
Copyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
Professional Caregiver Insurance RiskRisks to health care providers in arrangements like capitation contracts, DRGs, Medicare/Medicaid fee caps, & preferred provider relationships that inadequately fund needed/rendered care
Risks arising in budgeted nursing units subject to high variability in patient acuity, resource demands, equipment, supply shortages, mismatched patient needs/RN skills, and time constraints
Average Cost Based Reimbursement Plans (ACBRPs) force RNs into the roles of insurers – simultaneous clinical and financial decisions – who is minding the store? What are the ethical issues?
Bedside RNs forced to decide what services clients get and distribute scarce time and resources over too many patients, discharge acutely ill patients, manage gaps in care that are programmed in as recurrent & persistent features of care environments
Copyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
Professional Caregiver Insurance RiskInsurance risk transfers occur in financial contracts and intra-organizational budgets that inadequately fund caregiving functions and transfer insurance risks
Risk transfers may cause financial, professional, spiritual & affective disharmony on nursing units
Risk transfers may cause service quality
Recognizing and healing the professional, spiritual & affective wounds is critical to the well-being of RNs, nursing, nursing clients & the whole healthcare system
Copyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
Risk Induced Professional Caregiver Despair?RIPCD
Possible impacts on RNs of changes in healthcare finance mechanisms
access to quality healthcare.
Disrupted bonds between RNs and clients
Character, quality, & rapport of relationships
Issues neglected - need new tools/understandings to play a role in reshaping HC environment & finance issues
Some RNs despaired over lack of resources, workloads, unfamiliar staff, patients discharged too early
RNs had rich stories of the impact of working under fiscal constraints & risk transfersCopyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
How RIPCD Developed
Social work experiences
Nursing experiences
Insurance professional, social researcher, actuarial analyst and biostatistician experiences…
Peers at conferences, classes, & Christmas parties
Reflecting on roles, duties, and responsibilities of caregivers working under constraints and the similarities to insurance risk transfers
I needed a dissertation topic….
Copyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
Risk Induced Professional Caregiver Despair
RNs experiences, perceptions and expressions of RIPCD about their careers and working environments
Assumed there were good reasons for despair - not simply a biological, chemical, Rx deficit, or depression
Unmet expectations, unfulfilled hopes & dreams, opportunities lost, challenges too hard to meet, harsh and uninviting futures, and a past impossible to replicate or resurrect
Many RNs created new meanings for their experiences through their sharing,the researcher’s witnessing, and collaborating on developing their appreciative profiles, seeing themselves as wholes, representing & revealing their unique constructions of the world & their futures
Copyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
A Priori Assumptions about RIPCD
Burnout Depression
Unhappiness Anomie
Angst Dissatisfaction
Alienation Suffering
Stress Poor Attitude
Ethical Conflict Moral Distress
Mostly wrong!
Copyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
Unitary Appreciative Inquiry ITheory generation, practice & research method
Rogers Science of Unitary Human Beings
Appreciation of humans and human phenomena as wholes
Participants share experiences, perceptions & expressions, from their unique vantage point & without justifying themselves, their thoughts, beliefs, actions, or decisions
Goal – Appreciation of participants wholeness
Researcher sought a ‘healing appreciation of the participants’, not just capturing data about the experience
Praxis – not just research – RIPCD is a vehicle
Copyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
Unitary Appreciative InquiryCowling suggests that UAI has four (4) dimensions:
Pattern
Appreciation
Praxis
Power
and these advance and integrate four forms of unitary-transformative knowledge of particular concern to nursing:
Experiential
Presentational
Propositional
Practical
(Heron & Reason, 2001)
Copyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
Practicing Unitary Appreciative InquiryAcceptance and validation of participants
Empathy and appreciation: seeing through their eyes,
Seeking deeper understanding of the participants, as wholes
Healing intention - assist participants to freer expression, greater insight, and greater integration
Dwell in preconceptions & assumptions favorable to participants, fostering rapport & promoting a sense of harmony & mutuality
Participants are wholes but may feel ‘not-whole’
Assist participants in their healing appreciation of their wholeness, facilitating growth & transformation
Not just data collection – IRB issues
Copyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
RIPCD – A Unitary InquiryExperiences, intuitions, reflections about RNs RIPCD experiences
Collaborative, theorogenic, research, and healing journey
Opportunity to reveal, explore, and represent effects of HC financing experiments, adding substance, humanity, faces & feeling to the soulless explications that dominate
Participants shared experiences that highlighted the breadth and depth of the impact of risk transfers on nursing care and RNs in varied settings
Copyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
Why UAI Was ImportantWholeness and healing occurred because sufficient time and energy were devoted to free, unstructured, expression
Most participants thanked me for the opportunity to discuss their RIPCD until THEY were satisfied, citing prior inabilities to achieve a sense of closure
Some felt peers & superiors prematurely reacted, missing their legitimate concerns and seeing ‘staffing problems’ trying to ‘fix’ them or seeing them as ‘problem employees’
Appreciative profiles may be helpful to other disciplines and settings, addressing features of modern life & gaps between expectations & capacities under unanticipated and unplanned variability and unpredictabilityCopyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
Recruitment and Opening Dialogue
Participants sought through key informants, colleagues, flyers, presentations & attendees at past presentations
Opening question: “What does risk induced professional caregiver despair mean to you?”
Sometimes: “What makes your work as a nurse difficult?”
Most participants quickly focused on particular events in the workplace that dramatically affected them and their clients revealing serious deficiencies, inadequate staffing, scarce equipment, defective equipment, scarce supplies and some dramatically compelling experiences of inadequate and compromised care
Copyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
How The Research UnfoldedIn the early stages I wondered if people would be able to help me connect the dots. Then I wondered if they would…
RNs wanted to share their stories
Each RN provided new insights, helped to set a context for earlier/later stories about difficulty of bedside nursing
The question “What does risk induced professional caregiver despair mean to you” led to stories of the dramatic effects on nurses and clients of risk assumption and the erosion of what I now call “Nursing surplus” the organized, synergistic, capacity to provide high quality nursing care
Copyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
The Participants I
8 Registered Nurses
Self-identified as experiencing RIPCD
Volunteered to collaborate in an inquiry into effects on their practice of changes in HC financing mechanisms
Variety of nursing settings & experiences:
Oncology (2) Psych
Surgery Transplant/Oncology
Agency RN Maternity/ Pediatrics
Medical-Surgical
2 – 26 years as RNs
Copyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
The Participants IIOne participant, with business experience was well-informed on the insurance risk aspect
Most participants misinterpreted significant features of the environment:
Record keeping = Billing/Revenues
Patient Services = Billing/Revenues
Some opportunities to dialogue on my work on but participants and their world were the focus – sometimes would have interfered with the flow of the conversation
Most participants asked some questions about my work – I explained it only after in-depth interviews
Copyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
Thoughts on UAI as Dissertation Method
IRB – Difficult to explain ‘praxis’ to panels focused on risk reduction in designed experiments
How does one distinguish between healing intent and intervention to accomplish a specific outcome?
I never realized how out of control life could get – Hurricane Isabel helped me to appreciate that…
Much harder to get to be able to engage with participants than to engage with them…Copyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
What Were The End Products?
A hopefully soon to be completed dissertation
Four abstracts for presentations on PCIR/RIPCD based on the dissertation research (4 accepted)
Several future publications about the study findings, UAI, PCIR, RIPCD, nursing MISs, financial management…
Presentations on research, methodology, & PCIR
Develop tools for monitoring/maintaining nursing surplus under rapidly changing conditions of supply & demand
New venues for collaboration with other nurses, researchers, practitioners, educators & administrators
Copyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
During and After Inquiry
Allowed to freely consider, explore, and express their experiences, most of the RNs developed new ideas and attitudes about themselves and their RIPCD
Researcher gained important insights into how RNs respond to environmental impediments to caring practice
New theories and strategies for preparing RNs in new roles emerged – greater need to understand insurers, how to read and understand budgets & management reports, ethical reasoning regarding quality of care issues and conflicted loyalties
New ideas on healing for individuals, groups, and systemsCopyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
Some Guiding Principles of Healing Synoptic Narrative Construction
Allegory & metaphors encompass past, present & future
Collaborations, incorporated multiple modes of cognitive, affective, and aesthetic interpretation & representation
A reaching to incorporate past, present & different futures – a new way to focus clinical activity
Serving as a guide, reference point, healer, and co-inquirer, walking with participants on life path
Embrace contradiction, dissimilarity, and incoherence as birthing the futureCopyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
Appreciative ProfilesProfiles based on participant suggested sources:
The Scream – Home Alone (Macauley Culkin) OR Nurse
Voltaire’s Candide Oncology Nurse
Events in source materials woven with the events described by participants as interpreted by researcher – tremendous problem for aesthetically challenged researcher
Profiles developed with and approved by participants
Both participants and several others really liked my a priori hypothetical profile
Copyright 2004 Thomas Cox
http://www.standarderrors.org/Presentations/ISPN2004.PPT
A Hypothetical Unitary Appreciative Profile
http://www.standarderrors.org/Presentations/ISPN2004.PPT
Some Guiding Principles of Risk Induced Professional Caregiver DespairRhythm, flowing in & out of despair, hope, joy, pessimism
Not ‘observable’ - must engage participants
Experiences may be rare, constant, or never ‘resolved’
Emerging, shifting, changing, reforming coherence from time to time in an ever-changing environment
Most RN loved their jobs, peers, and nursing
For some, flooding their experiences out dramatically altered their lives, impelling them to action
Copyright 2004 Thomas Cox