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Integrating nursing: A holistic approach to the delivery of nursing care
Inl. J. Nurs. Stud. Vol. 16, pp. 215.230. ‘GPergamon Press Ltd., 1979. Printed in Great Britain.
0020.4848/79/0501-02l5
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IntegratingNursing: .a holisticapproach to the delivery of nursing care* M. GRYPDONCK, G. KOENE, M. TH. RODENBACH, T. WINDEY and J. E. BLANPAIN Research Unit for Hospital Administration and Medical Care Organization, School of Public Health, University of Leuven, Vital Decosterstraat 102, B-3000 Leuven, Belgium. Introduction
This ongoing action research project originated in 1972 in a research contract between the Ministry of Health of Belgium and the Department of Hospital Administration and Medical Care Organization of the University of Leuven, Belgium. The research contract was an outgrowth of the increasing awareness at the level of the Ministry of health of the difficulties that hospitals were facing in providing nursing care. The researchers were asked to define these difficulties and to make proposals for remedial action. The systems analysis approach was used to focus the research on the central activity of nurses: the delivery of nursing care. In this study the researchers accepted the responsibility for implementing their recommendations. This resulted in ongoing dialogue between the researchers and the nurses in the hospitals and provided the researchers with information about how their recommendations worked out. It led to the development of an implementation strategy and to a continuous development and refinement of the thinking of the researchers. This in turn led to changes in emphasis, to additions, and to refinement of the reorientation and implementation model. In the application of the reorientation and implementation model in the practice field, the practice settings have made alterations in the model, aiming at adapting the model to the local situation (with its own potentials and constraints). Consequently, the model has taken slightly different forms when put into practice in different hospitals. The implementation was closely followed, but not controlled, by the researchers. Through continuous contact with the field, the researchers were forced to assess the value and limitations of the recommendations. They were stimulated to develop instruments and methods for planning and implementing care; materials for continuing education, as the nurses in the practice field increase their ability to work with, and increase *“Integrating Nursing” is a research project of the Research Unit for Hospital Administration and Medical Care Organisation of the Department of Hospital Administration, School of Public Health, University of Leuven, Belgium. Project director is Prof. J. E. Blanpain, M.D. 215
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their knowledge about, the reorientation model. Five phases of the work in nursing practice settings in hospitals are described here. It is the intention of the research team to move into a sixth phase which will involve basic nursing education. 1. Phase I: Preparatory study (April 1972 - December 1972)
A. Diagnosis of difficulties in patient care in hospitals A first part of the study aimed at diagnosing the difficulties related to nursing care in hospitals which had a negative influence on the quality of care. To this extent, the professional activities of nurses in hospital units were analysed through the study of six parameters, considered representative for a systems approach of the nursing activities. The parameters studied were: (1) Dependency: examines whether the fact that an activity is carried out is dependent upon the presence of certain individuals with certain qualifications, certain skills, etc. Education: examines the correspondence between formal teaching (in the school) and (2) practical experience. (3) Training: examines what methods or means are in use to assist graduate nurses* to become proficient in a task or a function. Authorization: studies to what extent and in what way the performance of certain tasks (4) by nurses is restricted by legal, formal and informal regulations, to whatextentthese restrictions are respected and under what circumstances they are violated. (9 Regulations: examines formal and informal regulations which aim to regulate the work at the unit level (e.g. to what extent do formal prescriptions guide the work of the nurse, to what extent is the nurse autonomous - vti d vis the doctor and the head nurse, to what extent is the work regulated by explicit rules). (6) Evaluation: examines the extent to which events, occurrences, critical incidents, muses’ attitudes, etc. are evaluated by the head nurse and the nursing staff. To obtain information on these parameters, a questionnaire was used and administered by a nurse of the research staff, who was available for explanation when needed (all questionnaires were administered by the same nurse). Nurses were asked about occurrence of events and about situations in their work. The original plan for a national survey was abandoned after the results of the pilot sample had been analysed. The answers to the questionnaire showed a picture of nursing care and nursing care administration so far below expectations that further quantification was felt to be of limited value. The results of the pilot study questionnaire were used to formulate the difficulties nursing care in hospital were facing and these were then the starting point for a proposal for remedial action. B. Analysis of difficulties of nursing care in hospitals The difficulties which hospitals were facing were analysed. This analysis was based on rhe results and recommendations of previous research studies, on the results of the pilot study and on other observations of hospital care and related activities. The analysis can be summarized as follows: In the past there has been the problem of shortage of nursing staff and dissatisfaction *Graduate
nurses are nurses who have completed
a statutory
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in a nursing
school.
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with the discrepancy between desired quality of care and actual quality of care. To improve the situation in both areas, measures were taken which, although improving the problem at which they were directed, had undesirable consequences in other aspects. It was concluded that this piecemeal remedial action was contributing to the inadequacy of the measures taken. It was suggested that a proposal to improve the present situation would consist of an integrated set of measures, and that the consequence of each measure on other measures and on patient care as a whole would be carefully considered. 2. Phase II: Designing the reorientation model (February 1973 - December 1973) The construction and implementation of a reorientation model was based on the belief that when a set of measures is developed to bring about change in nursing care in the hospital, they should not only constitute a reorganization, but should allow for continuous and ongoing adaptation to changing needs and situations in the organization, in nursing, in the community served and in society. The proposed model should also aim at changing values and attitudes of people practicing in the hospital setting and enhance staff development. The model should not be too detailed, but only give the ‘headlines’ for the reorganization and be general in its ‘prescriptions’, in order to allow each hospital, nursing department and nursing unit to adapt it to its own situation, needs and resources. For these reasons, the term reorientation model (as opposed to reorganization model) was used. The approach to be used was much more akin to organization development than to reorganization alone. A. Definitions of objectives The proposed organization of nursing care was based on three general objectives. (1) A ‘central position’ should be accorded to the ‘patient as a person’. This means (a) that the patient is considered as a person with integrated somatic as well as nonsomatic needs; (b) that the organization adapts to the needs of the patient, rather than the patient to the needs of the organization. (2) The nurse is given a central position. The work environment of nurses should be motivating and stimulating, making demands on the highest abilities of the nurse. Responsibility should be delegated as far down the nursing hierarchy as possible. (3) The new organization should allow for the development of professional activity which manifests itself in the professional behaviour and self realisation of the nurse in such a way that the best interests of the patients are served. The new model should make a place for what is considered to be a specific function of the nursing profession: the integration of the somatic and non-somatic aspects of the care of the patient. B. Evaluation of existing models Existing models of change in the organization of nursing care in hospitals were examined in order to determine whether they would contribute to achieving the objectives, or to what extent they could provide a useful starting point. Four models were evaluated: (a) The model of the unit manager proposed by the Service Unit Management (SUM) (Jelinek, Munson and Smith, 1971).
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(b) The model of team nursing as proposed by Lambertsen (1953). (c) The model of THEM0 (therapeutic and motivating nursing) proposed by the Hospital Organization division of the Technische Hogeschool, Eindhoven (Merckx, 1972). (d) The model of team nursing as proposed by Bureau Berenschot (Management Consultants) and applied in the Netherlands in two hospitals at that time (Levert, 1972). To assess the value of the SUM report, a list of activities carried out on the nursing unit was made. The tasks were allocated by the advisory group and the researchers to either the head nurse, a registered nurse, an assistant nurse, a nursing auxiliary, a unit manager or a secretary. From this task allocation, it became apparent that a unit manager would contribute little to the solution of the problems of the nursing staff on the unit, especially since the unit manager does not have a nursing background. The three other models were evaluated by making explicit the influence of their constituent parts or main characteristics on the organization and practice of nursing on the nursing unit. It was apparent that no one model could be used without adaptation.
C. Modelfor reorientation of work on the nursing unit As no one model by itself was suited to achieving the central objectives, as they had been defined, it was concluded that the research staff in continuous interaction with the advisory group of nurses should develop its own model. The model grew piecemeal. It was built up from suitable measures obtained from existing models, measures from these models adapted by the research staff-the advisory group and some which originated from the research staff. The main contribution of the research staff and advisory group, however, consisted in synthesizing a coherent and comprehensive model of integrated measures, in which the relation of the measures to each other and to the whole were carefully scrutinized and evaluated. The set of measures, called the reorientation model, can be systematized as follows: (1) Reorientation of functions (a) The nurse -patient assignment to individual nurses. -the nurse is responsible for the total integrated nursing care of the patient (including planning, implementation, evaluation). -deliberate planning of care using systematized nursing intervention (nursing process approach). (b) Team leader -coordinates the work of a team. Gives assistance to less proficient team members. (c) Head nurse -renewed emphasis on leadership role, task-oriented and personnel oriented. (d) Ward-secretary (assistant) -to assist head nurse and nursing staff with non-nursing functions. (e) Coordinator -responsible for implementation of new developments in nursing care and administration. -is staff person working in several units. (2) Improvement of communication (a) Nursing care plans: written statements of what has to be done for the patient and
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its rationale. (b) Nursing records: written reports of what has been done to the patient and of observations made. (c) Group conference: patient centred discussion of the care of the patient by the head nurse and nursing staff. (d) Report: verbal communication of main points related to the care of patients each time responsibility for a patient is carried over from one person to another. (3) Allocation of time for nursing (a) Day schedule: instrument to schedule non-nursing activities around requirements of nursing care. (b) Patient profile: classification of patients according to amount and nature of care needed. 1. Reorientation of functions. A first set of measures concerns the functions of the persons involved in nursing. ‘Reorientation’ indicates that the proposed change is broader than, or different from, writing new ‘job descriptions’. The model envisages that the nursing personnel will function from a new perspective and give a new dimension to the work. The expected change is as much related to values, attitudes, knowledge and skills of the nurses, as it is to the organization. (a) The nurse. The nurse is given responsibility for the total nursing care of a limited number of patients. This means integrated nursing care for the patient, including somatic and non-somatic problems. It includes systematic planning and evaluation of the care, as well as the administration of the care. In order for the nurse to be able to achieve this, task assignment is replaced by patient assignment. An important feature is that the patient is not assigned to a group of nurses, but to an individual nurse. In assigning the patients, the head nurse tries to match the needs of the patients with the professional and personal characteristics and skills of the nurse. (b) The team leader. The team leader is responsible for the functioning of a group (subgroup) of nurses. She is not in an intermediate hierarchial administrative position. The team leader is a co-ordinator rather than a leader (the term ‘team leader’ is therefore somewhat misleading). She co-ordinates the work of the group. She explains the care plans to lower skilled personnel, calls attention to special aspects in the care of the patients, helps with those tasks an individual does not have the competence for, and is available to give advice and help. Even though the team leader gives help and advice to the team members, they are still responsible for the patients assigned to them. emphasis. (c) The head nurse. The leadership functions of the head nurse receive a renewed The head nurse is to function as a real leader of the nursing unit. Therefore she should be freed from tasks not requiring her level of skill and knowledge. These tasks can be delegated either to nurses, the team leader or to a secretary (or assistant). Some of the important leadership functions of head nurse which receive emphasis are designing and implementing methods for evaluation of quality of care, improving care, and staff development through increasing skills and knowledge of the nurses individually, and as a group. Group centred leadership functions become very important, and the head nurse is expected to give them full attention because of the high level of emotional involvement which can follow from patient assignment and responsibility for patient care. Creating a positive climate and increasing group cohesion are two other group centred functions necessary to enable personal involvement of the nurses. (e) The co-ordinator. He is a nurse, responsible for the implementation of new trends
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and developments in nursing, hospital administration, medicine and organization theory. The implementation of integrated nursing will be his first job. The co-ordinator is not attached to one unit, but functions as a staff person to a number of nursing units. 2. Improvement of communication. A second series of measures pertains to the communication between nurses, and between nurses and other hospital workers. Communication is of vital importance in achieving the objectives. It is also vital in ensuring continuity of care. A well organised communication network is essential to enable a nurse to discharge her responsibilities for providing total patient care. Four instruments have been devised to improve communication: (a) Nursing care plans: written plans which state the patients’ needs and what should be done for the patient. (b) Nursing records: written reports of what has to be done to the patient, what has been observed and progress of the patient, etc. (c) The group conference: a patient centred discussion. The care of the patients is discussed by the entire nursing staff of the ward, the data available among the nurses are brought together, suggestions for a plan of care are offered and discussed by the entire group. The head nurse or nurse responsible for the care of the patient have the opportunity to explain their decisions about what is to be done or should be done for her patient. The group conference has also a group centred function: it creates the opportunity to voice feelings and express anxiety; it can secure the support of the group for individual nurses. (d) The report: verbal communications of a shorter type. The report takes place any time a nurse hands over the responsibility for a patient, during and/or at the change of shifts. The aims are to give an overview of the problems encountered during the previous shift, and to supplement the written information. 3. Allocation of time for nursing. A third set of measures pertains to the time available for nursing. (a) By rescheduling activities using an instrument called ‘day schedule’, an attempt is made to make the best use of the time available for nursing. The aim is to increase the time nurses can have access to patients, without jeopardizing the efficiency of the supporting services. (b) ‘Patient profiles’ intend to classify patients according to the amount and nature of nursing care needed. They serve as a management tool for the head nurse to determine nurse/patient work-load and the work-load of the unit; and to the nursing service administration, in the short term, to allocate staff, and in the long term, to define the characteristics of the nursing unit. Although none of the measures proposed in the reorientation model were unique or new, the value of the model was considered to lie in the integration of the individual measures. The measures, as they were designed, constituted an integrated whole. As mentioned before, the model did not provide a detailed description of a new organization. However, the research staff, together with the advisory group of nurses, considered possible ways of making the model functional. The consequences of different alternatives were considered with regard to their feasibility and their possible contribution to reaching the objectives. At this point a name was given to the model. Preference was given to the term ‘Integrating Nursing’ because this name was considered to indicate the actual objectives: the concern for the patient as an integrated whole, the involvement of the nurse as a person in her work, and the integration of the needs of patients with the needs of the nurse who serves
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the interests of the patient by realizing herself in her work. ‘Integrating Nursing’ created a chance for the nurse to achieve real professional activity by requiring highly skilled performance, a high level of personal involvement, but most of all a specific function: the integration of physical and non-somatic care of the patient using a scientific approach.
D. Integrating Nursing: an integration of values in an operational model Integrating Nursing should not be seen as a set of measures pertaining to the organization of nursing care at nursing unit level. The organization of nursing care delivery is but one aspect of Integrating Nursing. The organization measures should be seen as the structure which promotes a conception of nursing, of the nurse-patient relationship and of the function of the nurse. The organization measures serve to make it possible to put these concepts into practice. Integrating Nursing requires specific attitudes and competencies of all nurses, including head nurses. Therefore, the values and skills of nurses are an integral part of this model and continuing education is an integral part of the introduction strategy. The most important aspects of beliefs and values incorporated in Integrated Nursing will be summarized in the following section.
1. Conception of nursing. (a) Nursing is the care of the individual as an integrated whole. Nursing care is directed at both the physical and psychosocial components, in an integrated way. Nursing care takes into consideration the interaction between man and his environment. It therefore pays special attention to the family, both as a receiver and giver of care. Nursing takes into account past life (and illness), experiences and is geared towards the future. Nursing care planning and implementation takes the established patterns and organization of the patient’s life into account and fosters the formation of new patterns and organization following an illness experience. Nursing gives full consideration to the patients capacity as a thinking and sentient human being (Rogers, 1970). (b) The nurse functions in the role of patient advocate, in a humanistic approach to health care (Chapman and Chapman, 1975). The nurse-patient relationship should have the characteristics of an adult-adult relationship (James and Jongeward, 1971). Self care of the patient, meaning responsibility for his own health and treatment, will be fostered. (c) Nursing care is a process in which assessment of patient’s needs is followed by a definition of nursing problems. Care is planned systematically. After implementation, the results achieved are evaluated and compared with desired results. Assessment, planning and evaluation have to be considered as a continuous process during the whole duration of the hospitalisation. (d) The nurse is personally responsible for the care of the total patient. She considers herself as being personally involved for the patient’s well being. This implies that the nurse does not focus on technical care or medically derived needs only, but focuses on the experience of the patient as being ill, as patient, as being hospitalized. 2. Beliefs about nurses. Workers have the right and the obligation to be personally involved in their work. The work situation should be demanding, in the sense that it appeals to the nurse as a person. It should give her an opportunity to realise her unique function: the integration of somatic and non-somatic care of the patient as a person. Real prof, essionalization comes about when the nurse can realize her unique function in a competent way.
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3. Beliefs about the organization. (a) Hospitals are among these complex organizations which cannot function effectively unless responsibility is delegated to as low a level in the hierarchy as possible, and is accepted by the workers. The responsibility for patient care should therefore lie primarily with the staff nurses. It should be up to them to plan and revise patient care for the patients assigned to them. (b) The nursing service in the hospital, as well as the entire hospital, needs to be in a process of continuing adaptation to changes and growth. Reorganizations cannot make an organization effective and efficient. An organization development approach is needed.
3. Phase III: Test of the model in the pilot hospital (January 1974 - December 1974) The next step was to examine the value of the model in a real situation. The aim was to see whether the objectives underlying the model would be reached and whether the difficulties envisaged would be resolved fully or at least partially when a nursing unit was reoriented according to the model. A. Selection of the pilot hospital A medium sized general hospital (150 beds) was asked to co-operate in putting the model into operation. The hospital selected was considered to be average regarding organization, resources and the quality of the nursing and other services provided. The hospital was chosen mainly on the basis of the willingness of the administrative and the nursing directors to co-operate. In the hospital, two nursing units were designated as pilot units. The units were designated by the hospital administrator and the director of nursing services. No alterations with regard to staffing were made prior to the project. B. Preparation of the nursing units (January 1974 - June 1974) The director of nursing service acted as co-ordinator. The research staff were to be ‘external advisers’. The director of nursing services had participated in the advisory group of nurses and was thus well acquainted with the reorientation model. Although in theory the director was to spend 50% of his time as co-ordinator for the project, his day-to-day work as director made this impossible. The nurses on the research team therefore took over most of the functions of the co-ordinator. This was an important limitation with respect to the co-ordinator’s function. The research nurses did not know the nurses, their abilities, their limitations, their relationship with each other and with the director; and they did not know the hospital. On the other hand this unforseen situation increased the degree of participant observation by the researchers to a considerable extent. In preparing the nursing units to make the change to ‘Integrating Nursing’, an implementation strategy was followed which was less well thought through than the reorientation model had been. Steps considered necessary by the research team were deleted or shortened under pressure by the hospital directors (e.g. it was impossible for the research staff to introduce extensive preparation of the nursing staff when the hospital administrators did not consider this necessary). C. Introduction of the integrated nursing model in the pilot units (July 1974) The integrated system was started on one unit and then in a second unit, two weeks later.
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In the model of ‘Integrating Nursing’, task assignment was replaced by patient assignment, the head nurse delegating the responsibility for the care of each patient to an individual nurse. She was assisted by a secretary for non-nursing duties. For each patient there was a ‘patient form’, a combination of patient care plan and patient record. Group conferences were held daily and change-of-shift-reports took place. During the period of introduction of the model, the research project nurses were almost continuously present in the hospital. The functions of the project nurses were the following: (1) to help the nursing staff and the head nurse whith problems which were due to their unfamiliarity with the new model; (2) to prevent mistakes which might be made due to the unfamiliarity with the new organization, new forms, etc.; (3) to advise on ad hoc changes in the original plan which might be necessary; (4) to prevent the making of changes or adaptations by the nurses or the head nurse (changes could be made, but they had to be deliberate and examined with regard to their necessity); (5) to increase gradually the sensitivity skill of the head nurse and nurses for Integrating Nursing; (6) to observe the development of the introduction of the model (from the point of view of the research). In fact, functions l-5 should have been fulfilled by the co-ordinator but this was apparently impossible for two reasons: (1) lack of time; (2) the threat resulting from a person from the ‘hierarchy’ being present at all times in the nursing unit and being so closely involved in its activities. D. Follow-up After a period of 8 weeks, the nurses of the research staff left the hospital. They returned each week for follow-up visits which were planned to take place when the units were having a more extensive group conference. Material discussed was brought up by the nurses. After a period of 4 months, the follow-up was turned over the co-ordinator. The benefits of the follow-up activities by the research staff were considered to be too low compared to the ‘costs’. Since it was not possible to follow closely the activities on the units, advice given was often inappropriate. E. Comments on the pilot hospital study The introduction of the model was in many ways defective. This was partly due to the position of the researchers vis d vis the hospital. The research staff was clearly asking a favour of the hospital. The hospital did not make the efforts necessary for the introduction of the plan, as it had been proposed to them. The researchers often could not justify their requests for time and the requirements for the preparation of the nursing staff. There was also the problem of the inexperience of the researchers: this was a pilot project and it had been impossible to forsee all the consequences of the actions taken. Although the introduction of the model had been very demanding on the research staff, it provided an abundance of participant observation data. Observations and occurrences were discussed among the research staff, and a diary was kept. A report of the experience in the pilot hospital was prepared in which a detailed description was given, the precise organization as worked out by the nurses was described, and comments were made on the organization, as
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well as on the introduction strategy. A formal evaluation of the test was not done. It was felt that this would be too threatening to the hospital staff. The necessary information was gained by participant observation. The research staff knew that the model could work, and they had important information about what would work and what would not work, as far as introduction strategy was concerned. Whether or not the model resulted in a measurable improvement of patient care in the pilot hospital had become an irrelevant question at this stage: negative results could easily be explained through ad hoc hypotheses about failures in the introduction strategy. The increase in staff satisfaction would theoretically have been measurable. Participant observation had made results of such a measurement invalid a priori: the relationship between the research nurses and the staff nurses and head nurses of the hospital had become too close; distortion of answers could not have been avoided. 4. Phase IV: Construction of an ‘introduction model’
An introduction model was constructed, based on the experience gained in the pilot hospital. This model gives guidelines for the introduction of Integrating Nursing in a hospital, which differ substantially from the implementation strategy used in the pilot study. The new model grew out of the critical reflection on that strategy and its consequences. The introduction model gives only headlines, as does the reorientation model, thus giving the opportunity (and necessity) of making a more elaborate plan in accordance with local circumstances. The implementation strategy will be discussed briefly. A. The co-ordinator The co-ordinator is the change agent who guides the implementation of Integrating Nursing. He/she is in a staff position to the director of nursing. The co-ordinator is a nurse, who has had experience in nursing in the hospital where he is to function. He has had education beyond the level of staff nurse. As a person, he needs to be non-authoritarian, to be able to delegate decision making, and to be accepted (or acceptable) by the head nurses and the nursing staff generally. As a nurse, he has to have, or be able to acquire, a vision of nursing which correlates with Integrating Nursing; it is necessary for him to see the patient as a person, and to see the function of the nurse as taking care of somatic and nonsomatic needs of the patient in an integrated way. He needs an additional purpose-oriented training related on the one hand to the content of nursing, and on the other hand to implementing the model of Integrated Nursing. His training needs to be directed to acquiring or developing both knowledge and skills. The role of the co-ordinator is vital and subtle. He is not the decision-maker, but needs to watch that at all levels all information needed to make appropriate decisions is available. He needs to be particularly careful not to take the place of those in the hierarchical line. He should not force decisions, but he has also to prevent the making of decisions before the consequences are carefully examined or before other alternatives are considered. He has the difficult task of guiding the whole process of implementation, without being the leader. B. Steps of the introduction model a. Preparation of the hospital. (1) Creating a problem awareness at the hospital and nursing administrators’ level. A
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preliminary condition for the success of the implementation of the model is that the hospital and nursing administration agree to implement the plan because of a realistic insight into the difficulties of nursing care in the hospital and into the possibilities that Integrating Nursing offers to remedy these difficulties. (2) The steering committee. The hospital administration has to agree to implement the plan and to accept the consequences of this decision. This agreement should be formalized. Then a steering committee should be installed in which problems related to the project are discussed. This steering committee is the expression of the support of the higher level functionaries in the hospital. Final decisions do not lie with the committee, however, but with the hospital and nursing administrators. (3) Information to the hospital staff. All the hospital workers should be informed about the project. They need to be given information about the aims of the project, and the consequences for themselves and for the units. The aim is to create an ‘open’ atmosphere which would avoid any feeling of threat or fear due to lack of information. (4) Information to the head nurse. A free choice by the head nurse to participate in the project is of the utmost importance. Therefore head nurses should be very well informed of the plan and its consequences. This should be done in formal meetings, as well as through informal contacts between head nurses and the co-ordinator. (5) Selection of nursing units. Two units should be selected because: (1) the co-ordinator would find it difficult to manage a large number; (2) if for any reason (external to the project) one unit failed to complete it, the other would provide information about its feasibility. The selection of the nursing unit must be based on free choice by the head nurse. It is felt that her personality, nursing characteristics and her leadership qualities play a major role in the extent to which the plan will be successful. The selection of the nursing units should be done by the co-ordinator, and be finalized in discussion between the steering committee and the hospital nursing administration.
b. Preparation of the nursing units. (1) Sensitization and preparation of the nursing staff. The nursing staff should be sensitized as to what the problems are in the present organization and administration of nursing care. They need to acquire the necessary knowledge and skills to administer Integrating Nursing. A formal training session will be necessary to reach this objective. (2) Developing the model to suit the situations. The next step is to form a working group which should include the head nurse, three or four nurses of the unit and the coordinator. Their function is to work out the precise organization of the work in their unit. The head nurse is responsible for the decisions made by the working group, but the co-ordinator needs to ensure that the input of the other nurses is respected. There needs to be a continuous and intensive information flow from the working group to the other nursing staff. The latter need to have the opportunity to make suggestions or voice criticism. The co-ordinator has to make sure that this reporting back and forth to the nursing staff takes place. (3) Approval by the steering committee. The decisions of the working group to be reported regularly to the steering committee. This committee can make comments and ask for revisions. When the working group has finished its task, including deciding on the starting date, the results should be presented as a whole to the steering committee and approved by the hospital administrators.
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(4) Immediate preparation of the nursing staff. Once the new organization has been finalized, the staff nurses should receive the opportunity to acquaint themselves with the new way of working and with the instruments (such as patient care forms, etc.). Formal training sessions will need to be organized by the co-ordinator and preferably led by the head nurse. c. Implementation. An appropriate starting date is selected when the maximum number of staff are available and the workload is expected to be low (e.g. operation days on surgical untis should be avoided). If other problems are present in the nursing unit, such as relationship problems between nursing staff and the administrators or between the head nurse and the nursing staff, they should be resolved before starting. On the starting day the new organization is implemented. Patient assignment is given to the nurses. They take on the responsibility for the total nursing care of their patients. Nursing care plans and patients’ records are used. There is a group discusssion and reports are given. The head nurse is responsible for ensuring that the arrangements made are respected. She assists the nurses in the care of their patients when needed, but carefully avoids interference with the concept of responsibility of the nurse. She leads the group conference and supports the nurses in their efforts to implement the plan. She gives special attention to emotional distress in the staff which may arise from patient assignment. The co-ordinator tries to intervene as little as possible. He should be careful not to take over the responsibility for running the unit since this responsibility needs to remain with the head nurse. He discusses with the head nurse changes which might have to be made in the proposed organization. He supports her in her efforts to increase the effectiveness of implementing the plan. d. Growth process: from reorganization to reorientation. With the implementation of the plan, a growth process is-hopefully-started. The head nurse and the staff nurse will need to “internalize” more and more the objectives of the plan. They will need to acquire additional skill and knowledge in using the instruments, and in planning and administering Integrating Nursing. To this end, it is necessary that the formal and informal teaching goes on after the implementation has started. Constant motivational encouragement of the nursing staff, stimulated by periodic evaluations, is necessary. It is one of the major functions of the co-ordinator to guide the growth process by stimulating and encouraging the personnel, helping the head nurse, teaching the nursing staff and arranging formal ‘educational’ sessions. e. Implementation of theplan in other units. Implementation of the plan in other units can be considered when the hospital nursing administrators, the steering committee, the head nurses and the nursing staff are satisfied with the state of affairs on the initial two units. This may also depend upon whether the co-ordinator feels that he can ‘release’ them. It is important to note that the preparatory phase for the second group of units should not be shortened, at least not to any great extent. The nurses and the head nurses of the second group of units should have the same introduction as the first two units. Personal involvement in deciding how the new organization is going to be, is considered a key element in the process of increasing the motivation of the nursing staff. It is formally contraindicated to assume that the acquaintance with the model of the coordinator and his experience and that of the steering committee justifies shortening the process of preparation at nursing unit level. It should not be overlooked that the nurses of the units of the second group have no ex-
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perience, that they need to overcome resistance to the same extent as the first group of units, and that participation in decision making about their work is as important for them as for the pilot units.
5. Phase V: Wider scale implementation of the model (May 1975)
After the test in the pilot hospital was done, and the results incorporated into the introduction model, an implementation in several hospitals was envisaged. This would allow at the same time a more reliable validation of the model itself, and a test of the introduction model. From a ‘service’ point of view (as opposed to research) it was felt necessary to provide guidance and assistance to the hospitals which wanted to implement the plan. The experience of the research staff in the pilot hospitals and their acquaintance with the model were felt to be necessary contributions towards implementing the plan in other hospitals at this stage. Under a contract of the Ministry of Health, it was possible to provide guidance for those hospitals which wanted to reorganize their nursing units. A plan for a wider scale implementation was then drawn up, which will be discussed briefly in the following paragraphs. A. Making Integrating Nursing known to hospital and nursing administrators It was felt desirable to make nursing and hospital administrators aware of the problems of nursing, as analyzed by the research team, and to make the proposal for remedial action known to them. Therefore a 4-day course was organized to which a team of hospital administrators, including nursing administrators, chiefs of medical staff and co-ordinators, if already appointed, were invited (December 1974-January 1975). During this course, which was part of the ongoing Continuing Education Activities of the Center for Hospital Administration, the analysis of the difficulties of providing nursing care, the model of Integrating Nursing and the implementation model were presented and discussed. The course was attended by administrators from 60 hospitals. B. Selection of hospitals Following the continuing education course, further contacts were made with those hospitals interested in implementing Integrating Nursing in the reasonably near future. The hospitals who wanted to participate were asked to appoint a co-ordinator who should be freed from other responsibilities during the training and implementation phase. Nine hospitals were selected to participate in the first phase of this wider scale implementation. C. Training the co-ordinator (May 1975 - September 1975) A 12-week training programme was arranged for co-ordinators, extending over a period of 20 weeks. The 12 weeks were arranged as follows, but each period did not necessarily immediately follow its predecessor: 2 weeks full time residential study, 3 weeks full time private study (at home), 1 week full time residential study, 5 weeks part time private study (at home), 1 week full time residential study. The training of the co-ordinator involved different aspects:
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(1) creating problem awareness; (2) acquiring in-depth knowledge of the model of Integrating Nursing; (3) acquiring knowledge and skills related to planned change in an organization; (4) acquiring knowledge and skills specific to the administration of Integrating Nursing (e.g. nursing care planning, total patient care, interaction with patients . . .); (5) acquiring knowledge and skills specific to the introduction and implementation of Integrating Nursing. The course was led by the research staff, who were assisted by organizational psychologists. During the residential part, lectures, discussions and exercises were used. Of particular interest was the use of a nursing unit simulation game, in which the co-ordinators simulated three days on a nursing unit. During the self-study weeks, which took place in between the residential course weeks, the co-ordinators read material selected by the research staff, pertaining to the topics mentioned above. Regional group discussions among coordinators were organized, in some of which the research staff participated.
D. Follow-up of the co-ordinators After the training had been completed, the co-ordinators were to implement the change in their own hospital. The guidelines given by the research staff were to be considered as guidelines only, not as directives. Each hospital moved at its own pace, and each hospital adapted the guidelines for implementation to its own needs and its particular situation. The precise form Integrating Nursing took in the participating hospitals showed different nuances. Since the co-ordinator had to work out a detailed organization model in cooperation with the nursing staff, it was obvious that different co-ordinators, working with different nurses in different situations, would find different answers to their problems. The implementation in the hospitals was closely followed by the research staff, but they did not participate. The only (but important) means to influence the work of the coordinators was by ‘coaching’ them and giving them advice and feed-back at monthly follow-up meetings. The follow-up meetings where the co-ordinators and the research staff come together are continuing and have several objectives. (1) To create a forum of sympathetic listeners for each co-ordinator, where they can voice their feelings, report their difficulties and receive advice and help. (2) To provide advice and help for particular and general problems that co-ordinators face in the implementation of Integrating Nursing. (3) To allow the research staff to maintain contact with the practice field and to receive feedback from practicing co-ordinators, in order to allow evaluation and modification of the reorientation and implementation models. (4) To stimulate the research staff to further develop ideas related to Integrating Nursing and to create the opportunity for implementation of these ideas in practice. (5) To provide opportunities for formal continuing education sessions for the co-ordinators Outside the monthly meetings, the co-ordinators can call on the research staff for advice or help with individual problems. Consultation-often by telephone-takes place regularly. The co-ordinators work in their respective hospitals and are responsible to the nursing service directors. They move at their own pace. At present, 7 hospitals have completed the introduction of their pilot units, and hospitals are implementing Integrating Nursing in a second or third series of units. Two hospitals are near completion of the “conversion”.
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E. Second trainingfor co-ordinators. Bridge to education During the 2 yr following the first training session of co-ordinators, repeated requests from several hospitals were directed to the research staff to organize a second course which would allow other hospitals to participate in the project. A training programme was set up, similar to the one in 1975. Changes were made, however, to accommodate the results of the development of the thinking of the research staff. Greater emphasis was placed on the Nursing Process, which had become a central part of the reorientation model. Coordinators from 12 hospitals participated. Based on the expressed need to bring about concomitant change in nursing education, co-ordinators from schools of nursing were admitted to the course. They came from schools using hospitals implementing or considering the implementation of Integrated Nursing. Thus pairs of co-ordinators were formed. The school co-ordinator was a nurse staff member with responsibility for the supervision of clinical practice and/or lectguring to student nurses. Hospital and school co-ordinators received joint training during the first part of the course. The last part was geared toward their specific function in the hospital or the school and was held separately for the two groups. This second course for coordinators took place in the period June 1977 - September 1977. F. Follow-up of co-ordinators A follow-up programme similar to the one established for the first group was set up. Monthly meetings are held, during which the research staff and other co-ordinators hear reports, share experiences and give advice. Three groups of co-ordinators are now followed up by the (same members of the) research staff -the co-ordinators trained in 1975 (hospital) -the co-ordinators trained in 1977 (hospital) -the school co-ordinators trained in 1977. Conclusion
After a diagnosis was made of the problems of nursing at nursing unit level, a proposal for reorientation of nursing care was made. This proposal, called Integrating Nursing, involved a reorganisation of nursing practice at nursing unit level, but, equally important, a new concept of nursing. To reach the goal of reorientation, a reorganization is carried out and the necessary instruments are provided. Training and close involvement of the nursing staff in the change process are essential for achieving the desired change in attitude. Professionalization of nursing, i.e. the realization of a unique function in a scientific way, leads to improved patient care and increased job satisfaction. The reorientation model has been tested in a pilot hospital. An implementation strategy was developed. Seven hospitals have reorganized several units, using the implementation strategy. They work under close monitoring of the research staff. A new group of coordinators has started implementation. Schools are involved in translating the consequences of Integrating Nursing in their educational programs. Formal evaluation has not yet been done. The implementation of Integrating Nursing creates possibilities for continuous improvement. This improvement originates in the hosRjta1, or in the continuous efforts of the research staff to refine, revise and re-emphasize aspects of the reorientation and im-
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plementation model. One example of this is that systematic nursing intervention (the nursing process) has become the expression of the core of Integrating Nursing. By its very nature-its emphasis on growth and development of nursing practice-Integrating Nursing lends itself to introduce new developments into practice. As activities of nurses become more visible, through patient care plans and records, group discussion and reports, the activities of nurses can be analysed. Patient assignment offers better opportunities for special approaches to be tested. Formal evaluation of nursing care of individual patients offers opportunities for quality assurance. Integrating Nursing thus creates a wide range of possibilities for improvement of patient care and nursing research.
References Chapman, J. and Chapman, H. H. (1975). Behavior and Health Care: a Humanistic Helping Process. Mosby, St. Louis. James, M. and Jongward, D. (1971). Born to Win: Transactional Analysis With Gestalt Experiments. AddisonWesley, Reading. Jelinek, R. C., Munson, F. and Smith R.L. (1971). SlJM(Service Unit Management). An Organisational Approach to Improved Patient Care. W. K. Kellogg Foundation, Battle Creek. Lambertson, E. C. (1953). Nursing Team Organization And Functioning. Teachers College Press, New York. Levert, A. J. (1972). Groepsverpleging-theorie en praktijk. Tijdschr. Ziekenverpl. Part I: 31, 1047-1054. Part II: 32, 1086-1091. Merckx, R. J. (1972). Verpleegkunde op weg naar een nieuw beroepsbeeld. Tijdschr. Ziekenverpl. 30, 1023-1028. (Received December
1978; acceptedforpublication
6 January 1979)
0020.4848/79/0501-02l5
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IntegratingNursing: .a holisticapproach to the delivery of nursing care* M. GRYPDONCK, G. KOENE, M. TH. RODENBACH, T. WINDEY and J. E. BLANPAIN Research Unit for Hospital Administration and Medical Care Organization, School of Public Health, University of Leuven, Vital Decosterstraat 102, B-3000 Leuven, Belgium. Introduction
This ongoing action research project originated in 1972 in a research contract between the Ministry of Health of Belgium and the Department of Hospital Administration and Medical Care Organization of the University of Leuven, Belgium. The research contract was an outgrowth of the increasing awareness at the level of the Ministry of health of the difficulties that hospitals were facing in providing nursing care. The researchers were asked to define these difficulties and to make proposals for remedial action. The systems analysis approach was used to focus the research on the central activity of nurses: the delivery of nursing care. In this study the researchers accepted the responsibility for implementing their recommendations. This resulted in ongoing dialogue between the researchers and the nurses in the hospitals and provided the researchers with information about how their recommendations worked out. It led to the development of an implementation strategy and to a continuous development and refinement of the thinking of the researchers. This in turn led to changes in emphasis, to additions, and to refinement of the reorientation and implementation model. In the application of the reorientation and implementation model in the practice field, the practice settings have made alterations in the model, aiming at adapting the model to the local situation (with its own potentials and constraints). Consequently, the model has taken slightly different forms when put into practice in different hospitals. The implementation was closely followed, but not controlled, by the researchers. Through continuous contact with the field, the researchers were forced to assess the value and limitations of the recommendations. They were stimulated to develop instruments and methods for planning and implementing care; materials for continuing education, as the nurses in the practice field increase their ability to work with, and increase *“Integrating Nursing” is a research project of the Research Unit for Hospital Administration and Medical Care Organisation of the Department of Hospital Administration, School of Public Health, University of Leuven, Belgium. Project director is Prof. J. E. Blanpain, M.D. 215
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their knowledge about, the reorientation model. Five phases of the work in nursing practice settings in hospitals are described here. It is the intention of the research team to move into a sixth phase which will involve basic nursing education. 1. Phase I: Preparatory study (April 1972 - December 1972)
A. Diagnosis of difficulties in patient care in hospitals A first part of the study aimed at diagnosing the difficulties related to nursing care in hospitals which had a negative influence on the quality of care. To this extent, the professional activities of nurses in hospital units were analysed through the study of six parameters, considered representative for a systems approach of the nursing activities. The parameters studied were: (1) Dependency: examines whether the fact that an activity is carried out is dependent upon the presence of certain individuals with certain qualifications, certain skills, etc. Education: examines the correspondence between formal teaching (in the school) and (2) practical experience. (3) Training: examines what methods or means are in use to assist graduate nurses* to become proficient in a task or a function. Authorization: studies to what extent and in what way the performance of certain tasks (4) by nurses is restricted by legal, formal and informal regulations, to whatextentthese restrictions are respected and under what circumstances they are violated. (9 Regulations: examines formal and informal regulations which aim to regulate the work at the unit level (e.g. to what extent do formal prescriptions guide the work of the nurse, to what extent is the nurse autonomous - vti d vis the doctor and the head nurse, to what extent is the work regulated by explicit rules). (6) Evaluation: examines the extent to which events, occurrences, critical incidents, muses’ attitudes, etc. are evaluated by the head nurse and the nursing staff. To obtain information on these parameters, a questionnaire was used and administered by a nurse of the research staff, who was available for explanation when needed (all questionnaires were administered by the same nurse). Nurses were asked about occurrence of events and about situations in their work. The original plan for a national survey was abandoned after the results of the pilot sample had been analysed. The answers to the questionnaire showed a picture of nursing care and nursing care administration so far below expectations that further quantification was felt to be of limited value. The results of the pilot study questionnaire were used to formulate the difficulties nursing care in hospital were facing and these were then the starting point for a proposal for remedial action. B. Analysis of difficulties of nursing care in hospitals The difficulties which hospitals were facing were analysed. This analysis was based on rhe results and recommendations of previous research studies, on the results of the pilot study and on other observations of hospital care and related activities. The analysis can be summarized as follows: In the past there has been the problem of shortage of nursing staff and dissatisfaction *Graduate
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with the discrepancy between desired quality of care and actual quality of care. To improve the situation in both areas, measures were taken which, although improving the problem at which they were directed, had undesirable consequences in other aspects. It was concluded that this piecemeal remedial action was contributing to the inadequacy of the measures taken. It was suggested that a proposal to improve the present situation would consist of an integrated set of measures, and that the consequence of each measure on other measures and on patient care as a whole would be carefully considered. 2. Phase II: Designing the reorientation model (February 1973 - December 1973) The construction and implementation of a reorientation model was based on the belief that when a set of measures is developed to bring about change in nursing care in the hospital, they should not only constitute a reorganization, but should allow for continuous and ongoing adaptation to changing needs and situations in the organization, in nursing, in the community served and in society. The proposed model should also aim at changing values and attitudes of people practicing in the hospital setting and enhance staff development. The model should not be too detailed, but only give the ‘headlines’ for the reorganization and be general in its ‘prescriptions’, in order to allow each hospital, nursing department and nursing unit to adapt it to its own situation, needs and resources. For these reasons, the term reorientation model (as opposed to reorganization model) was used. The approach to be used was much more akin to organization development than to reorganization alone. A. Definitions of objectives The proposed organization of nursing care was based on three general objectives. (1) A ‘central position’ should be accorded to the ‘patient as a person’. This means (a) that the patient is considered as a person with integrated somatic as well as nonsomatic needs; (b) that the organization adapts to the needs of the patient, rather than the patient to the needs of the organization. (2) The nurse is given a central position. The work environment of nurses should be motivating and stimulating, making demands on the highest abilities of the nurse. Responsibility should be delegated as far down the nursing hierarchy as possible. (3) The new organization should allow for the development of professional activity which manifests itself in the professional behaviour and self realisation of the nurse in such a way that the best interests of the patients are served. The new model should make a place for what is considered to be a specific function of the nursing profession: the integration of the somatic and non-somatic aspects of the care of the patient. B. Evaluation of existing models Existing models of change in the organization of nursing care in hospitals were examined in order to determine whether they would contribute to achieving the objectives, or to what extent they could provide a useful starting point. Four models were evaluated: (a) The model of the unit manager proposed by the Service Unit Management (SUM) (Jelinek, Munson and Smith, 1971).
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(b) The model of team nursing as proposed by Lambertsen (1953). (c) The model of THEM0 (therapeutic and motivating nursing) proposed by the Hospital Organization division of the Technische Hogeschool, Eindhoven (Merckx, 1972). (d) The model of team nursing as proposed by Bureau Berenschot (Management Consultants) and applied in the Netherlands in two hospitals at that time (Levert, 1972). To assess the value of the SUM report, a list of activities carried out on the nursing unit was made. The tasks were allocated by the advisory group and the researchers to either the head nurse, a registered nurse, an assistant nurse, a nursing auxiliary, a unit manager or a secretary. From this task allocation, it became apparent that a unit manager would contribute little to the solution of the problems of the nursing staff on the unit, especially since the unit manager does not have a nursing background. The three other models were evaluated by making explicit the influence of their constituent parts or main characteristics on the organization and practice of nursing on the nursing unit. It was apparent that no one model could be used without adaptation.
C. Modelfor reorientation of work on the nursing unit As no one model by itself was suited to achieving the central objectives, as they had been defined, it was concluded that the research staff in continuous interaction with the advisory group of nurses should develop its own model. The model grew piecemeal. It was built up from suitable measures obtained from existing models, measures from these models adapted by the research staff-the advisory group and some which originated from the research staff. The main contribution of the research staff and advisory group, however, consisted in synthesizing a coherent and comprehensive model of integrated measures, in which the relation of the measures to each other and to the whole were carefully scrutinized and evaluated. The set of measures, called the reorientation model, can be systematized as follows: (1) Reorientation of functions (a) The nurse -patient assignment to individual nurses. -the nurse is responsible for the total integrated nursing care of the patient (including planning, implementation, evaluation). -deliberate planning of care using systematized nursing intervention (nursing process approach). (b) Team leader -coordinates the work of a team. Gives assistance to less proficient team members. (c) Head nurse -renewed emphasis on leadership role, task-oriented and personnel oriented. (d) Ward-secretary (assistant) -to assist head nurse and nursing staff with non-nursing functions. (e) Coordinator -responsible for implementation of new developments in nursing care and administration. -is staff person working in several units. (2) Improvement of communication (a) Nursing care plans: written statements of what has to be done for the patient and
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its rationale. (b) Nursing records: written reports of what has been done to the patient and of observations made. (c) Group conference: patient centred discussion of the care of the patient by the head nurse and nursing staff. (d) Report: verbal communication of main points related to the care of patients each time responsibility for a patient is carried over from one person to another. (3) Allocation of time for nursing (a) Day schedule: instrument to schedule non-nursing activities around requirements of nursing care. (b) Patient profile: classification of patients according to amount and nature of care needed. 1. Reorientation of functions. A first set of measures concerns the functions of the persons involved in nursing. ‘Reorientation’ indicates that the proposed change is broader than, or different from, writing new ‘job descriptions’. The model envisages that the nursing personnel will function from a new perspective and give a new dimension to the work. The expected change is as much related to values, attitudes, knowledge and skills of the nurses, as it is to the organization. (a) The nurse. The nurse is given responsibility for the total nursing care of a limited number of patients. This means integrated nursing care for the patient, including somatic and non-somatic problems. It includes systematic planning and evaluation of the care, as well as the administration of the care. In order for the nurse to be able to achieve this, task assignment is replaced by patient assignment. An important feature is that the patient is not assigned to a group of nurses, but to an individual nurse. In assigning the patients, the head nurse tries to match the needs of the patients with the professional and personal characteristics and skills of the nurse. (b) The team leader. The team leader is responsible for the functioning of a group (subgroup) of nurses. She is not in an intermediate hierarchial administrative position. The team leader is a co-ordinator rather than a leader (the term ‘team leader’ is therefore somewhat misleading). She co-ordinates the work of the group. She explains the care plans to lower skilled personnel, calls attention to special aspects in the care of the patients, helps with those tasks an individual does not have the competence for, and is available to give advice and help. Even though the team leader gives help and advice to the team members, they are still responsible for the patients assigned to them. emphasis. (c) The head nurse. The leadership functions of the head nurse receive a renewed The head nurse is to function as a real leader of the nursing unit. Therefore she should be freed from tasks not requiring her level of skill and knowledge. These tasks can be delegated either to nurses, the team leader or to a secretary (or assistant). Some of the important leadership functions of head nurse which receive emphasis are designing and implementing methods for evaluation of quality of care, improving care, and staff development through increasing skills and knowledge of the nurses individually, and as a group. Group centred leadership functions become very important, and the head nurse is expected to give them full attention because of the high level of emotional involvement which can follow from patient assignment and responsibility for patient care. Creating a positive climate and increasing group cohesion are two other group centred functions necessary to enable personal involvement of the nurses. (e) The co-ordinator. He is a nurse, responsible for the implementation of new trends
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and developments in nursing, hospital administration, medicine and organization theory. The implementation of integrated nursing will be his first job. The co-ordinator is not attached to one unit, but functions as a staff person to a number of nursing units. 2. Improvement of communication. A second series of measures pertains to the communication between nurses, and between nurses and other hospital workers. Communication is of vital importance in achieving the objectives. It is also vital in ensuring continuity of care. A well organised communication network is essential to enable a nurse to discharge her responsibilities for providing total patient care. Four instruments have been devised to improve communication: (a) Nursing care plans: written plans which state the patients’ needs and what should be done for the patient. (b) Nursing records: written reports of what has to be done to the patient, what has been observed and progress of the patient, etc. (c) The group conference: a patient centred discussion. The care of the patients is discussed by the entire nursing staff of the ward, the data available among the nurses are brought together, suggestions for a plan of care are offered and discussed by the entire group. The head nurse or nurse responsible for the care of the patient have the opportunity to explain their decisions about what is to be done or should be done for her patient. The group conference has also a group centred function: it creates the opportunity to voice feelings and express anxiety; it can secure the support of the group for individual nurses. (d) The report: verbal communications of a shorter type. The report takes place any time a nurse hands over the responsibility for a patient, during and/or at the change of shifts. The aims are to give an overview of the problems encountered during the previous shift, and to supplement the written information. 3. Allocation of time for nursing. A third set of measures pertains to the time available for nursing. (a) By rescheduling activities using an instrument called ‘day schedule’, an attempt is made to make the best use of the time available for nursing. The aim is to increase the time nurses can have access to patients, without jeopardizing the efficiency of the supporting services. (b) ‘Patient profiles’ intend to classify patients according to the amount and nature of nursing care needed. They serve as a management tool for the head nurse to determine nurse/patient work-load and the work-load of the unit; and to the nursing service administration, in the short term, to allocate staff, and in the long term, to define the characteristics of the nursing unit. Although none of the measures proposed in the reorientation model were unique or new, the value of the model was considered to lie in the integration of the individual measures. The measures, as they were designed, constituted an integrated whole. As mentioned before, the model did not provide a detailed description of a new organization. However, the research staff, together with the advisory group of nurses, considered possible ways of making the model functional. The consequences of different alternatives were considered with regard to their feasibility and their possible contribution to reaching the objectives. At this point a name was given to the model. Preference was given to the term ‘Integrating Nursing’ because this name was considered to indicate the actual objectives: the concern for the patient as an integrated whole, the involvement of the nurse as a person in her work, and the integration of the needs of patients with the needs of the nurse who serves
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the interests of the patient by realizing herself in her work. ‘Integrating Nursing’ created a chance for the nurse to achieve real professional activity by requiring highly skilled performance, a high level of personal involvement, but most of all a specific function: the integration of physical and non-somatic care of the patient using a scientific approach.
D. Integrating Nursing: an integration of values in an operational model Integrating Nursing should not be seen as a set of measures pertaining to the organization of nursing care at nursing unit level. The organization of nursing care delivery is but one aspect of Integrating Nursing. The organization measures should be seen as the structure which promotes a conception of nursing, of the nurse-patient relationship and of the function of the nurse. The organization measures serve to make it possible to put these concepts into practice. Integrating Nursing requires specific attitudes and competencies of all nurses, including head nurses. Therefore, the values and skills of nurses are an integral part of this model and continuing education is an integral part of the introduction strategy. The most important aspects of beliefs and values incorporated in Integrated Nursing will be summarized in the following section.
1. Conception of nursing. (a) Nursing is the care of the individual as an integrated whole. Nursing care is directed at both the physical and psychosocial components, in an integrated way. Nursing care takes into consideration the interaction between man and his environment. It therefore pays special attention to the family, both as a receiver and giver of care. Nursing takes into account past life (and illness), experiences and is geared towards the future. Nursing care planning and implementation takes the established patterns and organization of the patient’s life into account and fosters the formation of new patterns and organization following an illness experience. Nursing gives full consideration to the patients capacity as a thinking and sentient human being (Rogers, 1970). (b) The nurse functions in the role of patient advocate, in a humanistic approach to health care (Chapman and Chapman, 1975). The nurse-patient relationship should have the characteristics of an adult-adult relationship (James and Jongeward, 1971). Self care of the patient, meaning responsibility for his own health and treatment, will be fostered. (c) Nursing care is a process in which assessment of patient’s needs is followed by a definition of nursing problems. Care is planned systematically. After implementation, the results achieved are evaluated and compared with desired results. Assessment, planning and evaluation have to be considered as a continuous process during the whole duration of the hospitalisation. (d) The nurse is personally responsible for the care of the total patient. She considers herself as being personally involved for the patient’s well being. This implies that the nurse does not focus on technical care or medically derived needs only, but focuses on the experience of the patient as being ill, as patient, as being hospitalized. 2. Beliefs about nurses. Workers have the right and the obligation to be personally involved in their work. The work situation should be demanding, in the sense that it appeals to the nurse as a person. It should give her an opportunity to realise her unique function: the integration of somatic and non-somatic care of the patient as a person. Real prof, essionalization comes about when the nurse can realize her unique function in a competent way.
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3. Beliefs about the organization. (a) Hospitals are among these complex organizations which cannot function effectively unless responsibility is delegated to as low a level in the hierarchy as possible, and is accepted by the workers. The responsibility for patient care should therefore lie primarily with the staff nurses. It should be up to them to plan and revise patient care for the patients assigned to them. (b) The nursing service in the hospital, as well as the entire hospital, needs to be in a process of continuing adaptation to changes and growth. Reorganizations cannot make an organization effective and efficient. An organization development approach is needed.
3. Phase III: Test of the model in the pilot hospital (January 1974 - December 1974) The next step was to examine the value of the model in a real situation. The aim was to see whether the objectives underlying the model would be reached and whether the difficulties envisaged would be resolved fully or at least partially when a nursing unit was reoriented according to the model. A. Selection of the pilot hospital A medium sized general hospital (150 beds) was asked to co-operate in putting the model into operation. The hospital selected was considered to be average regarding organization, resources and the quality of the nursing and other services provided. The hospital was chosen mainly on the basis of the willingness of the administrative and the nursing directors to co-operate. In the hospital, two nursing units were designated as pilot units. The units were designated by the hospital administrator and the director of nursing services. No alterations with regard to staffing were made prior to the project. B. Preparation of the nursing units (January 1974 - June 1974) The director of nursing service acted as co-ordinator. The research staff were to be ‘external advisers’. The director of nursing services had participated in the advisory group of nurses and was thus well acquainted with the reorientation model. Although in theory the director was to spend 50% of his time as co-ordinator for the project, his day-to-day work as director made this impossible. The nurses on the research team therefore took over most of the functions of the co-ordinator. This was an important limitation with respect to the co-ordinator’s function. The research nurses did not know the nurses, their abilities, their limitations, their relationship with each other and with the director; and they did not know the hospital. On the other hand this unforseen situation increased the degree of participant observation by the researchers to a considerable extent. In preparing the nursing units to make the change to ‘Integrating Nursing’, an implementation strategy was followed which was less well thought through than the reorientation model had been. Steps considered necessary by the research team were deleted or shortened under pressure by the hospital directors (e.g. it was impossible for the research staff to introduce extensive preparation of the nursing staff when the hospital administrators did not consider this necessary). C. Introduction of the integrated nursing model in the pilot units (July 1974) The integrated system was started on one unit and then in a second unit, two weeks later.
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In the model of ‘Integrating Nursing’, task assignment was replaced by patient assignment, the head nurse delegating the responsibility for the care of each patient to an individual nurse. She was assisted by a secretary for non-nursing duties. For each patient there was a ‘patient form’, a combination of patient care plan and patient record. Group conferences were held daily and change-of-shift-reports took place. During the period of introduction of the model, the research project nurses were almost continuously present in the hospital. The functions of the project nurses were the following: (1) to help the nursing staff and the head nurse whith problems which were due to their unfamiliarity with the new model; (2) to prevent mistakes which might be made due to the unfamiliarity with the new organization, new forms, etc.; (3) to advise on ad hoc changes in the original plan which might be necessary; (4) to prevent the making of changes or adaptations by the nurses or the head nurse (changes could be made, but they had to be deliberate and examined with regard to their necessity); (5) to increase gradually the sensitivity skill of the head nurse and nurses for Integrating Nursing; (6) to observe the development of the introduction of the model (from the point of view of the research). In fact, functions l-5 should have been fulfilled by the co-ordinator but this was apparently impossible for two reasons: (1) lack of time; (2) the threat resulting from a person from the ‘hierarchy’ being present at all times in the nursing unit and being so closely involved in its activities. D. Follow-up After a period of 8 weeks, the nurses of the research staff left the hospital. They returned each week for follow-up visits which were planned to take place when the units were having a more extensive group conference. Material discussed was brought up by the nurses. After a period of 4 months, the follow-up was turned over the co-ordinator. The benefits of the follow-up activities by the research staff were considered to be too low compared to the ‘costs’. Since it was not possible to follow closely the activities on the units, advice given was often inappropriate. E. Comments on the pilot hospital study The introduction of the model was in many ways defective. This was partly due to the position of the researchers vis d vis the hospital. The research staff was clearly asking a favour of the hospital. The hospital did not make the efforts necessary for the introduction of the plan, as it had been proposed to them. The researchers often could not justify their requests for time and the requirements for the preparation of the nursing staff. There was also the problem of the inexperience of the researchers: this was a pilot project and it had been impossible to forsee all the consequences of the actions taken. Although the introduction of the model had been very demanding on the research staff, it provided an abundance of participant observation data. Observations and occurrences were discussed among the research staff, and a diary was kept. A report of the experience in the pilot hospital was prepared in which a detailed description was given, the precise organization as worked out by the nurses was described, and comments were made on the organization, as
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well as on the introduction strategy. A formal evaluation of the test was not done. It was felt that this would be too threatening to the hospital staff. The necessary information was gained by participant observation. The research staff knew that the model could work, and they had important information about what would work and what would not work, as far as introduction strategy was concerned. Whether or not the model resulted in a measurable improvement of patient care in the pilot hospital had become an irrelevant question at this stage: negative results could easily be explained through ad hoc hypotheses about failures in the introduction strategy. The increase in staff satisfaction would theoretically have been measurable. Participant observation had made results of such a measurement invalid a priori: the relationship between the research nurses and the staff nurses and head nurses of the hospital had become too close; distortion of answers could not have been avoided. 4. Phase IV: Construction of an ‘introduction model’
An introduction model was constructed, based on the experience gained in the pilot hospital. This model gives guidelines for the introduction of Integrating Nursing in a hospital, which differ substantially from the implementation strategy used in the pilot study. The new model grew out of the critical reflection on that strategy and its consequences. The introduction model gives only headlines, as does the reorientation model, thus giving the opportunity (and necessity) of making a more elaborate plan in accordance with local circumstances. The implementation strategy will be discussed briefly. A. The co-ordinator The co-ordinator is the change agent who guides the implementation of Integrating Nursing. He/she is in a staff position to the director of nursing. The co-ordinator is a nurse, who has had experience in nursing in the hospital where he is to function. He has had education beyond the level of staff nurse. As a person, he needs to be non-authoritarian, to be able to delegate decision making, and to be accepted (or acceptable) by the head nurses and the nursing staff generally. As a nurse, he has to have, or be able to acquire, a vision of nursing which correlates with Integrating Nursing; it is necessary for him to see the patient as a person, and to see the function of the nurse as taking care of somatic and nonsomatic needs of the patient in an integrated way. He needs an additional purpose-oriented training related on the one hand to the content of nursing, and on the other hand to implementing the model of Integrated Nursing. His training needs to be directed to acquiring or developing both knowledge and skills. The role of the co-ordinator is vital and subtle. He is not the decision-maker, but needs to watch that at all levels all information needed to make appropriate decisions is available. He needs to be particularly careful not to take the place of those in the hierarchical line. He should not force decisions, but he has also to prevent the making of decisions before the consequences are carefully examined or before other alternatives are considered. He has the difficult task of guiding the whole process of implementation, without being the leader. B. Steps of the introduction model a. Preparation of the hospital. (1) Creating a problem awareness at the hospital and nursing administrators’ level. A
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preliminary condition for the success of the implementation of the model is that the hospital and nursing administration agree to implement the plan because of a realistic insight into the difficulties of nursing care in the hospital and into the possibilities that Integrating Nursing offers to remedy these difficulties. (2) The steering committee. The hospital administration has to agree to implement the plan and to accept the consequences of this decision. This agreement should be formalized. Then a steering committee should be installed in which problems related to the project are discussed. This steering committee is the expression of the support of the higher level functionaries in the hospital. Final decisions do not lie with the committee, however, but with the hospital and nursing administrators. (3) Information to the hospital staff. All the hospital workers should be informed about the project. They need to be given information about the aims of the project, and the consequences for themselves and for the units. The aim is to create an ‘open’ atmosphere which would avoid any feeling of threat or fear due to lack of information. (4) Information to the head nurse. A free choice by the head nurse to participate in the project is of the utmost importance. Therefore head nurses should be very well informed of the plan and its consequences. This should be done in formal meetings, as well as through informal contacts between head nurses and the co-ordinator. (5) Selection of nursing units. Two units should be selected because: (1) the co-ordinator would find it difficult to manage a large number; (2) if for any reason (external to the project) one unit failed to complete it, the other would provide information about its feasibility. The selection of the nursing unit must be based on free choice by the head nurse. It is felt that her personality, nursing characteristics and her leadership qualities play a major role in the extent to which the plan will be successful. The selection of the nursing units should be done by the co-ordinator, and be finalized in discussion between the steering committee and the hospital nursing administration.
b. Preparation of the nursing units. (1) Sensitization and preparation of the nursing staff. The nursing staff should be sensitized as to what the problems are in the present organization and administration of nursing care. They need to acquire the necessary knowledge and skills to administer Integrating Nursing. A formal training session will be necessary to reach this objective. (2) Developing the model to suit the situations. The next step is to form a working group which should include the head nurse, three or four nurses of the unit and the coordinator. Their function is to work out the precise organization of the work in their unit. The head nurse is responsible for the decisions made by the working group, but the co-ordinator needs to ensure that the input of the other nurses is respected. There needs to be a continuous and intensive information flow from the working group to the other nursing staff. The latter need to have the opportunity to make suggestions or voice criticism. The co-ordinator has to make sure that this reporting back and forth to the nursing staff takes place. (3) Approval by the steering committee. The decisions of the working group to be reported regularly to the steering committee. This committee can make comments and ask for revisions. When the working group has finished its task, including deciding on the starting date, the results should be presented as a whole to the steering committee and approved by the hospital administrators.
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(4) Immediate preparation of the nursing staff. Once the new organization has been finalized, the staff nurses should receive the opportunity to acquaint themselves with the new way of working and with the instruments (such as patient care forms, etc.). Formal training sessions will need to be organized by the co-ordinator and preferably led by the head nurse. c. Implementation. An appropriate starting date is selected when the maximum number of staff are available and the workload is expected to be low (e.g. operation days on surgical untis should be avoided). If other problems are present in the nursing unit, such as relationship problems between nursing staff and the administrators or between the head nurse and the nursing staff, they should be resolved before starting. On the starting day the new organization is implemented. Patient assignment is given to the nurses. They take on the responsibility for the total nursing care of their patients. Nursing care plans and patients’ records are used. There is a group discusssion and reports are given. The head nurse is responsible for ensuring that the arrangements made are respected. She assists the nurses in the care of their patients when needed, but carefully avoids interference with the concept of responsibility of the nurse. She leads the group conference and supports the nurses in their efforts to implement the plan. She gives special attention to emotional distress in the staff which may arise from patient assignment. The co-ordinator tries to intervene as little as possible. He should be careful not to take over the responsibility for running the unit since this responsibility needs to remain with the head nurse. He discusses with the head nurse changes which might have to be made in the proposed organization. He supports her in her efforts to increase the effectiveness of implementing the plan. d. Growth process: from reorganization to reorientation. With the implementation of the plan, a growth process is-hopefully-started. The head nurse and the staff nurse will need to “internalize” more and more the objectives of the plan. They will need to acquire additional skill and knowledge in using the instruments, and in planning and administering Integrating Nursing. To this end, it is necessary that the formal and informal teaching goes on after the implementation has started. Constant motivational encouragement of the nursing staff, stimulated by periodic evaluations, is necessary. It is one of the major functions of the co-ordinator to guide the growth process by stimulating and encouraging the personnel, helping the head nurse, teaching the nursing staff and arranging formal ‘educational’ sessions. e. Implementation of theplan in other units. Implementation of the plan in other units can be considered when the hospital nursing administrators, the steering committee, the head nurses and the nursing staff are satisfied with the state of affairs on the initial two units. This may also depend upon whether the co-ordinator feels that he can ‘release’ them. It is important to note that the preparatory phase for the second group of units should not be shortened, at least not to any great extent. The nurses and the head nurses of the second group of units should have the same introduction as the first two units. Personal involvement in deciding how the new organization is going to be, is considered a key element in the process of increasing the motivation of the nursing staff. It is formally contraindicated to assume that the acquaintance with the model of the coordinator and his experience and that of the steering committee justifies shortening the process of preparation at nursing unit level. It should not be overlooked that the nurses of the units of the second group have no ex-
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perience, that they need to overcome resistance to the same extent as the first group of units, and that participation in decision making about their work is as important for them as for the pilot units.
5. Phase V: Wider scale implementation of the model (May 1975)
After the test in the pilot hospital was done, and the results incorporated into the introduction model, an implementation in several hospitals was envisaged. This would allow at the same time a more reliable validation of the model itself, and a test of the introduction model. From a ‘service’ point of view (as opposed to research) it was felt necessary to provide guidance and assistance to the hospitals which wanted to implement the plan. The experience of the research staff in the pilot hospitals and their acquaintance with the model were felt to be necessary contributions towards implementing the plan in other hospitals at this stage. Under a contract of the Ministry of Health, it was possible to provide guidance for those hospitals which wanted to reorganize their nursing units. A plan for a wider scale implementation was then drawn up, which will be discussed briefly in the following paragraphs. A. Making Integrating Nursing known to hospital and nursing administrators It was felt desirable to make nursing and hospital administrators aware of the problems of nursing, as analyzed by the research team, and to make the proposal for remedial action known to them. Therefore a 4-day course was organized to which a team of hospital administrators, including nursing administrators, chiefs of medical staff and co-ordinators, if already appointed, were invited (December 1974-January 1975). During this course, which was part of the ongoing Continuing Education Activities of the Center for Hospital Administration, the analysis of the difficulties of providing nursing care, the model of Integrating Nursing and the implementation model were presented and discussed. The course was attended by administrators from 60 hospitals. B. Selection of hospitals Following the continuing education course, further contacts were made with those hospitals interested in implementing Integrating Nursing in the reasonably near future. The hospitals who wanted to participate were asked to appoint a co-ordinator who should be freed from other responsibilities during the training and implementation phase. Nine hospitals were selected to participate in the first phase of this wider scale implementation. C. Training the co-ordinator (May 1975 - September 1975) A 12-week training programme was arranged for co-ordinators, extending over a period of 20 weeks. The 12 weeks were arranged as follows, but each period did not necessarily immediately follow its predecessor: 2 weeks full time residential study, 3 weeks full time private study (at home), 1 week full time residential study, 5 weeks part time private study (at home), 1 week full time residential study. The training of the co-ordinator involved different aspects:
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(1) creating problem awareness; (2) acquiring in-depth knowledge of the model of Integrating Nursing; (3) acquiring knowledge and skills related to planned change in an organization; (4) acquiring knowledge and skills specific to the administration of Integrating Nursing (e.g. nursing care planning, total patient care, interaction with patients . . .); (5) acquiring knowledge and skills specific to the introduction and implementation of Integrating Nursing. The course was led by the research staff, who were assisted by organizational psychologists. During the residential part, lectures, discussions and exercises were used. Of particular interest was the use of a nursing unit simulation game, in which the co-ordinators simulated three days on a nursing unit. During the self-study weeks, which took place in between the residential course weeks, the co-ordinators read material selected by the research staff, pertaining to the topics mentioned above. Regional group discussions among coordinators were organized, in some of which the research staff participated.
D. Follow-up of the co-ordinators After the training had been completed, the co-ordinators were to implement the change in their own hospital. The guidelines given by the research staff were to be considered as guidelines only, not as directives. Each hospital moved at its own pace, and each hospital adapted the guidelines for implementation to its own needs and its particular situation. The precise form Integrating Nursing took in the participating hospitals showed different nuances. Since the co-ordinator had to work out a detailed organization model in cooperation with the nursing staff, it was obvious that different co-ordinators, working with different nurses in different situations, would find different answers to their problems. The implementation in the hospitals was closely followed by the research staff, but they did not participate. The only (but important) means to influence the work of the coordinators was by ‘coaching’ them and giving them advice and feed-back at monthly follow-up meetings. The follow-up meetings where the co-ordinators and the research staff come together are continuing and have several objectives. (1) To create a forum of sympathetic listeners for each co-ordinator, where they can voice their feelings, report their difficulties and receive advice and help. (2) To provide advice and help for particular and general problems that co-ordinators face in the implementation of Integrating Nursing. (3) To allow the research staff to maintain contact with the practice field and to receive feedback from practicing co-ordinators, in order to allow evaluation and modification of the reorientation and implementation models. (4) To stimulate the research staff to further develop ideas related to Integrating Nursing and to create the opportunity for implementation of these ideas in practice. (5) To provide opportunities for formal continuing education sessions for the co-ordinators Outside the monthly meetings, the co-ordinators can call on the research staff for advice or help with individual problems. Consultation-often by telephone-takes place regularly. The co-ordinators work in their respective hospitals and are responsible to the nursing service directors. They move at their own pace. At present, 7 hospitals have completed the introduction of their pilot units, and hospitals are implementing Integrating Nursing in a second or third series of units. Two hospitals are near completion of the “conversion”.
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E. Second trainingfor co-ordinators. Bridge to education During the 2 yr following the first training session of co-ordinators, repeated requests from several hospitals were directed to the research staff to organize a second course which would allow other hospitals to participate in the project. A training programme was set up, similar to the one in 1975. Changes were made, however, to accommodate the results of the development of the thinking of the research staff. Greater emphasis was placed on the Nursing Process, which had become a central part of the reorientation model. Coordinators from 12 hospitals participated. Based on the expressed need to bring about concomitant change in nursing education, co-ordinators from schools of nursing were admitted to the course. They came from schools using hospitals implementing or considering the implementation of Integrated Nursing. Thus pairs of co-ordinators were formed. The school co-ordinator was a nurse staff member with responsibility for the supervision of clinical practice and/or lectguring to student nurses. Hospital and school co-ordinators received joint training during the first part of the course. The last part was geared toward their specific function in the hospital or the school and was held separately for the two groups. This second course for coordinators took place in the period June 1977 - September 1977. F. Follow-up of co-ordinators A follow-up programme similar to the one established for the first group was set up. Monthly meetings are held, during which the research staff and other co-ordinators hear reports, share experiences and give advice. Three groups of co-ordinators are now followed up by the (same members of the) research staff -the co-ordinators trained in 1975 (hospital) -the co-ordinators trained in 1977 (hospital) -the school co-ordinators trained in 1977. Conclusion
After a diagnosis was made of the problems of nursing at nursing unit level, a proposal for reorientation of nursing care was made. This proposal, called Integrating Nursing, involved a reorganisation of nursing practice at nursing unit level, but, equally important, a new concept of nursing. To reach the goal of reorientation, a reorganization is carried out and the necessary instruments are provided. Training and close involvement of the nursing staff in the change process are essential for achieving the desired change in attitude. Professionalization of nursing, i.e. the realization of a unique function in a scientific way, leads to improved patient care and increased job satisfaction. The reorientation model has been tested in a pilot hospital. An implementation strategy was developed. Seven hospitals have reorganized several units, using the implementation strategy. They work under close monitoring of the research staff. A new group of coordinators has started implementation. Schools are involved in translating the consequences of Integrating Nursing in their educational programs. Formal evaluation has not yet been done. The implementation of Integrating Nursing creates possibilities for continuous improvement. This improvement originates in the hosRjta1, or in the continuous efforts of the research staff to refine, revise and re-emphasize aspects of the reorientation and im-
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plementation model. One example of this is that systematic nursing intervention (the nursing process) has become the expression of the core of Integrating Nursing. By its very nature-its emphasis on growth and development of nursing practice-Integrating Nursing lends itself to introduce new developments into practice. As activities of nurses become more visible, through patient care plans and records, group discussion and reports, the activities of nurses can be analysed. Patient assignment offers better opportunities for special approaches to be tested. Formal evaluation of nursing care of individual patients offers opportunities for quality assurance. Integrating Nursing thus creates a wide range of possibilities for improvement of patient care and nursing research.
References Chapman, J. and Chapman, H. H. (1975). Behavior and Health Care: a Humanistic Helping Process. Mosby, St. Louis. James, M. and Jongward, D. (1971). Born to Win: Transactional Analysis With Gestalt Experiments. AddisonWesley, Reading. Jelinek, R. C., Munson, F. and Smith R.L. (1971). SlJM(Service Unit Management). An Organisational Approach to Improved Patient Care. W. K. Kellogg Foundation, Battle Creek. Lambertson, E. C. (1953). Nursing Team Organization And Functioning. Teachers College Press, New York. Levert, A. J. (1972). Groepsverpleging-theorie en praktijk. Tijdschr. Ziekenverpl. Part I: 31, 1047-1054. Part II: 32, 1086-1091. Merckx, R. J. (1972). Verpleegkunde op weg naar een nieuw beroepsbeeld. Tijdschr. Ziekenverpl. 30, 1023-1028. (Received December
1978; acceptedforpublication
6 January 1979)