- Email: [email protected]
Translating Caring Theory into Practice: A Relationship-Based Care Experience
Translating Caring Theory into Practice: A Relationship-Based Care Experience Jean Mellott, MSN, RN-BC, Karen Richards, DNP, RN, NE-BC, Lianne Tonry, MN, RN-BC, NE-BC, Anne Marie H. Bularzik, DNP, RN, NE-BC, and Mary Palmer, MBA, RN
T
he chief executive officer (CEO) of Exeter Hospital in Exeter, New Hampshire, challenged senior leadership to propose innovative strategies for improving organizational excellence. The chief nursing executive (CNE) offered the Magnet® journey as one such strategy. Based on the existing research, the consideration of Magnet was so compelling that the CEO and senior leadership unanimously agreed to embark on the journey toward excellence. As the shared governance model emerged, nursing blossomed. Structures and processes were developed to transform practice and advance the professional culture of nursing.The CNE and the Nursing Leadership Council explored theoretical frameworks that would complement and align with the existing culture of nursing.The framework also needed to have an interdisciplinary dimension since quality care is inextricably linked to highly
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functioning and collaborative care teams. A literature review led the group to caring theories and Swanson’s Middle Range Theory of Care.The model selected to operationalize the theory was Relationship-Based Care (RBC). Following RBC leadership training, senior management and the board of trustees decided to adopt RBC as the model for all patient interactions. Underscoring the organization-wide commitment to RBC, the CEO changed the organization's vision statement, highlighting the importance of relationships.
STRUCTURE A steering committee comprising of the CNE, a senior nurse vice president (VP), the Magnet director, the director for professional development and clinical support, a nursing professional development specialist with previous Magnet and RBC
October 2012
Figure 1. Commitment to Patients and Families
Figure 2. Sample Survey Results Before and After RBC Implementation
experience, and later, the director of patient care experience was formed. Meetings centered on learning the concepts, discussing opportunities for inspiring organizational commitment, and designing a strategic plan to utilize the framework of RBC. Initially, there were more questions than answers. Who would attend phase one training? Is training mandatory? How will training be facilitated, hardwired into practice, and sustained? Perhaps most importantly: how will success be tracked, measured, and reported? Weekly meetings provided inspiration and created the energy to construct the shared vision for an enhanced caring practice.
PROCESS The steering committee became the training team. Staff training focused on an in-depth review of the six dimensions of RBC, Swanson’s Theory of Caring, creating a vision and leading change, delegation, teamwork, developing guidelines for unit-based practice councils (UBPCs), and service communication. Notebooks containing each day’s handouts were provided, as well as a separate workbook of corresponding materials specifically selected to provide greater depth and understanding of various topics. Five units were selected to begin the RBC roll-out. Each unit chose five to six staff members, plus the manager to attend four 8-hour days of intensive training. Each team identified co-leaders to act as liaisons to the steering committee and to be responsible for providing education and inspiration to colleagues. Attention was paid to the learning environment: for example, tables arranged in pods, music during registration, and coffee coupons. Managers were asked at times to sit separately so staff could feel unencumbered to discuss unit www.nurseleader.com
issues or concerns. Each pod had a basket of markers, poster paper, and role cards to foster learner engagement during the group activities (leader, recorder, reporter, and timekeeper). Ample time was built into the curriculum, with activities designed to encourage staff to work together. The group activities portion proved to be the biggest satisfier at every session. Meetings with the steering committee were scheduled every 6 weeks for a year post training, which allowed teams the opportunity to network, share success stories, clarify and refocus goals. The check-ins provided structure for teams to successfully meet goals and deadlines. Appreciation for the power of stories began to flourish as moments of excellence were captured and shared. Nurses were intentionally demonstrating caring and knowing, with patients clearly seeing the benefits. For example, a medical-surgical nurse asked an elderly woman what was most important to her on that day. “My rosary beads,” she replied. The nurse made phone calls and arranged for the beads to be delivered. Less than 24 hours later, the woman peacefully died. The story has been told many times, and one question invariably emerges, what if the nurse had not taken the time to ask? By day 4 of training, the teams had refined their unit’s guiding documents (vision statements: Commitment to Patients and Families, shown in Figure 1; Commitment to Coworkers; and Managers' Commitment to Staff) and developed an implementation plan. One project proposed by the endoscopy unit was to create a NURSE badge in large font that could be easily read from a distance. Widely accepted and adopted house-wide, nurses and licensed nursing assistants presently receive role badges upon hire. RBC was introduced to the units with a week-long series of events and activities. Teams created storyboards to share guiding documents and implementation plans. While the teams were gaining traction, RBC Essentials classes were held for ancillary and support departments. One question often repeated was “I am not in a clinical role. What does RBC have to do with me?” This provided the perfect segue into sharing a quote from Healing With Heart1 and helped to set context for the importance of RBC for every person in the organization: “For every person who touches a patient, there are three unseen employees supporting that caregiver. Every one is needed. While we may have differing gifts, no one individual need be valued more than another.”1(p58)
OUTCOMES After implementation, an electronic staff survey examined the impact of RBC at the unit level. Using a five-point Likert scale, staff rated the impact pre- and post-RBC, using each statement from their Commitment to Coworkers document. The results affirmed that RBC had, indeed, had a positive impact on teamwork and collegiality (Figure 2). Subsequently, three more teams were trained in 6-month intervals. New teams learned from prior participants who were eager to share knowledge of RBC and their unique stories of inspiration. Peers were now teaching peers about
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Figure 3. RBC Web Site
RBC. RBC began to ignite throughout the organization as patient care areas operationalized the tenets. In the intensive care unit (ICU), quiet time was implemented. At predictable times each afternoon, lights are dimmed, conversations are intentionally lowered, while patients rest uninterrupted, able to experience healing at the most fundamental level. Phase III teams (Family Center, Surgical Services, and Emergency Department) were the most interesting and dynamic of all the phases. All three had previously participated in TeamSTEPPS™ training. Having that established foundation of teamwork and a shared mental model made for lively and engaged discussions around patient care and the work of a UBPC. The teams adopted the red badge/green badge project that had sprung up during the first phase of training and added red squares to the reverse side of the badge. Team members flash the red square for an immediate concern or the need to halt a conversation until a more appropriate time. Green squares provide an opportunity for recognition of a positive interaction.
Figure 4. RBC Newsletter
SUSTAINABILITY During the final phase of training, discussions arose about how best to sustain RBC. An RBC Web site was developed (Figure 3) to inform staff about ongoing activities, and a newsletter was created to provide context and further explain the initiative (Figure 4). Nursing Summit, a quarterly, 2-hour meeting for UBPC leaders, master council leaders, and the CNE, continues to provide a forum to focus on RBC and professional practice. Meetings highlight one RBC dimension. For example, the leadership content included a review of Swanson’s theory, Transformational Leadership, and linkages to the organization’s mission, vision, and values. Attendees used the caring processes and Transformational Leadership Cycle to evaluate a unit change/process improvement project from the leadership perspective.
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Ongoing sustainability efforts involve the integration of RBC with other organization-wide initiatives, TeamSTEPPS™, Lean Process Design, and Service Continued on page 49
October 2012
Translating Caring Theory Continued from page 46
Communication. Examples of venues for such integration include corporate and clinical orientations. RBC enculturation also involves educating student nurses and clinical instructors. Student nurses and faculty meet at the beginning of each clinical rotation with the RBC project leader. Students receive information about RBC, what it looks like in the organization, and what it means to patients and families. Students are encouraged to share their observations of RBC in action, including instances of teamwork and patient-focused communication.
CONCLUSION RBC has deepened the organization’s commitment and accountability to patients and families. The most credible measure of the extent to which RBC is alive is how an organization feels to someone new. The following are comments and observations from the organization’s interim VP of Acute Care Services. “I began my orientation by observing the provision of care. The professionalism was exemplary and the impression given is that the nurses have all the time in the world to be with the patient. There is a very personal sense of commitment, and responsibility. “Every council meeting starts with Moments of Excellence…and there are always many stories to share. Exeter Hospital is committed to patient care in a very genuine, grassroots way. There is no ‘window dressing’ here. People walk the talk, and the patients benefit every day. It is clear this is a ‘patient-focused’ organization.” NL Reference 1. Helldorfer M, Moss, T. Healing With Heart: Inspirations for Health Care Professionals. Orinda, CA: Moss Communications; 2007. Web site. www.mosscommunications.net. Accessed June 20, 2012.
Jean Mellott, MSN, RN-BC, Karen Richards, DNP, RN, NEBC, Lianne Tonry, MN, RN-BC, NE-BC, Anne Marie H. Bularzik, DNP, RN, NE-BC, and Mary Palmer, MBA, RN, are members of the RBC Steering Committee at Exeter Hospital in Exeter, New Hampshire. Mellott can be reached at [email protected], Richards at [email protected], Tonry at [email protected], Bularzik at [email protected], and Palmer at [email protected]. 1541-4612/2012/ $ See front matter Copyright 2012 by Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2012.02.006
www.nurseleader.com
Nurse Leader
49
T
he chief executive officer (CEO) of Exeter Hospital in Exeter, New Hampshire, challenged senior leadership to propose innovative strategies for improving organizational excellence. The chief nursing executive (CNE) offered the Magnet® journey as one such strategy. Based on the existing research, the consideration of Magnet was so compelling that the CEO and senior leadership unanimously agreed to embark on the journey toward excellence. As the shared governance model emerged, nursing blossomed. Structures and processes were developed to transform practice and advance the professional culture of nursing.The CNE and the Nursing Leadership Council explored theoretical frameworks that would complement and align with the existing culture of nursing.The framework also needed to have an interdisciplinary dimension since quality care is inextricably linked to highly
44
Nurse Leader
functioning and collaborative care teams. A literature review led the group to caring theories and Swanson’s Middle Range Theory of Care.The model selected to operationalize the theory was Relationship-Based Care (RBC). Following RBC leadership training, senior management and the board of trustees decided to adopt RBC as the model for all patient interactions. Underscoring the organization-wide commitment to RBC, the CEO changed the organization's vision statement, highlighting the importance of relationships.
STRUCTURE A steering committee comprising of the CNE, a senior nurse vice president (VP), the Magnet director, the director for professional development and clinical support, a nursing professional development specialist with previous Magnet and RBC
October 2012
Figure 1. Commitment to Patients and Families
Figure 2. Sample Survey Results Before and After RBC Implementation
experience, and later, the director of patient care experience was formed. Meetings centered on learning the concepts, discussing opportunities for inspiring organizational commitment, and designing a strategic plan to utilize the framework of RBC. Initially, there were more questions than answers. Who would attend phase one training? Is training mandatory? How will training be facilitated, hardwired into practice, and sustained? Perhaps most importantly: how will success be tracked, measured, and reported? Weekly meetings provided inspiration and created the energy to construct the shared vision for an enhanced caring practice.
PROCESS The steering committee became the training team. Staff training focused on an in-depth review of the six dimensions of RBC, Swanson’s Theory of Caring, creating a vision and leading change, delegation, teamwork, developing guidelines for unit-based practice councils (UBPCs), and service communication. Notebooks containing each day’s handouts were provided, as well as a separate workbook of corresponding materials specifically selected to provide greater depth and understanding of various topics. Five units were selected to begin the RBC roll-out. Each unit chose five to six staff members, plus the manager to attend four 8-hour days of intensive training. Each team identified co-leaders to act as liaisons to the steering committee and to be responsible for providing education and inspiration to colleagues. Attention was paid to the learning environment: for example, tables arranged in pods, music during registration, and coffee coupons. Managers were asked at times to sit separately so staff could feel unencumbered to discuss unit www.nurseleader.com
issues or concerns. Each pod had a basket of markers, poster paper, and role cards to foster learner engagement during the group activities (leader, recorder, reporter, and timekeeper). Ample time was built into the curriculum, with activities designed to encourage staff to work together. The group activities portion proved to be the biggest satisfier at every session. Meetings with the steering committee were scheduled every 6 weeks for a year post training, which allowed teams the opportunity to network, share success stories, clarify and refocus goals. The check-ins provided structure for teams to successfully meet goals and deadlines. Appreciation for the power of stories began to flourish as moments of excellence were captured and shared. Nurses were intentionally demonstrating caring and knowing, with patients clearly seeing the benefits. For example, a medical-surgical nurse asked an elderly woman what was most important to her on that day. “My rosary beads,” she replied. The nurse made phone calls and arranged for the beads to be delivered. Less than 24 hours later, the woman peacefully died. The story has been told many times, and one question invariably emerges, what if the nurse had not taken the time to ask? By day 4 of training, the teams had refined their unit’s guiding documents (vision statements: Commitment to Patients and Families, shown in Figure 1; Commitment to Coworkers; and Managers' Commitment to Staff) and developed an implementation plan. One project proposed by the endoscopy unit was to create a NURSE badge in large font that could be easily read from a distance. Widely accepted and adopted house-wide, nurses and licensed nursing assistants presently receive role badges upon hire. RBC was introduced to the units with a week-long series of events and activities. Teams created storyboards to share guiding documents and implementation plans. While the teams were gaining traction, RBC Essentials classes were held for ancillary and support departments. One question often repeated was “I am not in a clinical role. What does RBC have to do with me?” This provided the perfect segue into sharing a quote from Healing With Heart1 and helped to set context for the importance of RBC for every person in the organization: “For every person who touches a patient, there are three unseen employees supporting that caregiver. Every one is needed. While we may have differing gifts, no one individual need be valued more than another.”1(p58)
OUTCOMES After implementation, an electronic staff survey examined the impact of RBC at the unit level. Using a five-point Likert scale, staff rated the impact pre- and post-RBC, using each statement from their Commitment to Coworkers document. The results affirmed that RBC had, indeed, had a positive impact on teamwork and collegiality (Figure 2). Subsequently, three more teams were trained in 6-month intervals. New teams learned from prior participants who were eager to share knowledge of RBC and their unique stories of inspiration. Peers were now teaching peers about
Nurse Leader
45
Figure 3. RBC Web Site
RBC. RBC began to ignite throughout the organization as patient care areas operationalized the tenets. In the intensive care unit (ICU), quiet time was implemented. At predictable times each afternoon, lights are dimmed, conversations are intentionally lowered, while patients rest uninterrupted, able to experience healing at the most fundamental level. Phase III teams (Family Center, Surgical Services, and Emergency Department) were the most interesting and dynamic of all the phases. All three had previously participated in TeamSTEPPS™ training. Having that established foundation of teamwork and a shared mental model made for lively and engaged discussions around patient care and the work of a UBPC. The teams adopted the red badge/green badge project that had sprung up during the first phase of training and added red squares to the reverse side of the badge. Team members flash the red square for an immediate concern or the need to halt a conversation until a more appropriate time. Green squares provide an opportunity for recognition of a positive interaction.
Figure 4. RBC Newsletter
SUSTAINABILITY During the final phase of training, discussions arose about how best to sustain RBC. An RBC Web site was developed (Figure 3) to inform staff about ongoing activities, and a newsletter was created to provide context and further explain the initiative (Figure 4). Nursing Summit, a quarterly, 2-hour meeting for UBPC leaders, master council leaders, and the CNE, continues to provide a forum to focus on RBC and professional practice. Meetings highlight one RBC dimension. For example, the leadership content included a review of Swanson’s theory, Transformational Leadership, and linkages to the organization’s mission, vision, and values. Attendees used the caring processes and Transformational Leadership Cycle to evaluate a unit change/process improvement project from the leadership perspective.
46
Nurse Leader
Ongoing sustainability efforts involve the integration of RBC with other organization-wide initiatives, TeamSTEPPS™, Lean Process Design, and Service Continued on page 49
October 2012
Translating Caring Theory Continued from page 46
Communication. Examples of venues for such integration include corporate and clinical orientations. RBC enculturation also involves educating student nurses and clinical instructors. Student nurses and faculty meet at the beginning of each clinical rotation with the RBC project leader. Students receive information about RBC, what it looks like in the organization, and what it means to patients and families. Students are encouraged to share their observations of RBC in action, including instances of teamwork and patient-focused communication.
CONCLUSION RBC has deepened the organization’s commitment and accountability to patients and families. The most credible measure of the extent to which RBC is alive is how an organization feels to someone new. The following are comments and observations from the organization’s interim VP of Acute Care Services. “I began my orientation by observing the provision of care. The professionalism was exemplary and the impression given is that the nurses have all the time in the world to be with the patient. There is a very personal sense of commitment, and responsibility. “Every council meeting starts with Moments of Excellence…and there are always many stories to share. Exeter Hospital is committed to patient care in a very genuine, grassroots way. There is no ‘window dressing’ here. People walk the talk, and the patients benefit every day. It is clear this is a ‘patient-focused’ organization.” NL Reference 1. Helldorfer M, Moss, T. Healing With Heart: Inspirations for Health Care Professionals. Orinda, CA: Moss Communications; 2007. Web site. www.mosscommunications.net. Accessed June 20, 2012.
Jean Mellott, MSN, RN-BC, Karen Richards, DNP, RN, NEBC, Lianne Tonry, MN, RN-BC, NE-BC, Anne Marie H. Bularzik, DNP, RN, NE-BC, and Mary Palmer, MBA, RN, are members of the RBC Steering Committee at Exeter Hospital in Exeter, New Hampshire. Mellott can be reached at [email protected], Richards at [email protected], Tonry at [email protected], Bularzik at [email protected], and Palmer at [email protected]. 1541-4612/2012/ $ See front matter Copyright 2012 by Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2012.02.006
www.nurseleader.com
Nurse Leader
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