- Email: [email protected]
Creating Caring Connections Through Presence
Creating Caring Connections Through Presence Mary O’Connor, PhD, RN, FACHE
I
n a dramatic scene in the film Miracle on 34th
ly. According to Merriam-Webster,2 presence is
Street, the idealistic lawyer asserts that we
defined first as person-to-person physical presence,
should “not overlook those lovely intangibles, as
or in her/his direct vicinity, or being with a thing that
we’ll find out in the end they are the only things that
is “visible and concrete.” But more importantly,
really matter.” Presence is one of those intangibles,
another more elusive presence is “something (as a
an abstract concept that cannot be measured direct-
spirit) felt or believed to be present.”2
1
www.nurseleader.com
Nurse Leader
347
T
he philosopher Gabriel Marcel3 describes presence as a mystery. It is experienced, but difficult to put into words. In other words, presence is something that is “sensed.” It communicates knowing between 2 or more persons beyond physical closeness or the words spoken. Additionally, true presence can only be felt by the other. Marcel would challenge, for example, that I cannot be instructed or counseled into making my presence felt. It may be likened to a feeling of spiritual or emotional connection between people that is beyond the physical closeness. To further complicate this, the “feeling” of presence is often unconsciously taken for granted and most conspicuous in its absence. It is not difficult to ascertain if someone is physically present but attentively absent. The purpose of this article is to describe and illustrate the perspective and importance of presence for students completing a graduate program in nursing administration. In addition, strategies and implications of strengthening presence for nurse leaders are offered.
PRESENCE IN NURSING The connection between presence and caring is made through many scholars in the work of caring science.4 Most explicitly, presence as a necessary component of caring is visible in the theory works of Jean Watson5 and Kristin Swanson.6 In her Caritas Processes, Watson identifies presence directly: “Being authentically present and enabling and sustaining the deep belief system and subjective life world of self and one-being cared for.”5(p.256) Additionally, she implies the importance of presence in other phrases throughout these processes such as “intentional caring consciousness,” and “developing and sustaining a helping-trusting, authentic caring relationship.”5(p.256) Likewise, Swanson’s 5 caring processes include “being-with” the patient/family as the way in which understanding is created.6 She writes: “In many ways to be-with another is to give simply of the self and to do so in such a way that the one cared for realizes the commitment, concern, and personal attentiveness of the one caring.”6(p.355) In her seminal work, Healing Presence: The Essence of Nursing, Joellen Koerner7 calls being present with another an act of courage. It is the courage to learn, she says, as well as the curiosity and desire to engage in authentic relationship that is needed to deepen learning. She goes on to say: A nurse healer in the postmodern world creates an atmosphere of openness and safety, which invites compassion, clarity, and truth to enter. To effectively do this, the nurse must radiate her or his own soul qualities. A nonjudging presence invites those same qualities…This creates a shared environment that potentiates the self-healing capacity of both the person and the nurse.7(p.131) In order to be present and feel present with another person or even a group, there must be a connection. The environment must be conducive for this connection to occur allowing trust, caring, and vulnerability, in other words, a culture of safety.
348
Nurse Leader
LEADERSHIP PRESENCE Recently, there has been writing and research on executive presence. In one study done in Australia, the authors found several personal characteristics that influence people’s perceptions of their leaders’ presence.8 These include how the leaders present themselves physically, communicate (i.e., confidently and intellectually), use power, and their appearing to live their values or having integrity. In addition, although impressions were formed during initial interactions, in the end, they were based on whether or not the initial assessment stood over time. This is congruent with Turpin’s9 finding that presence is a process of acting. She states: “Leadership presence is outwardly focused on projection of image to achieve connections and followership, instead of the interpersonal connection itself.”9(p.16) Formal authority does not automatically confer true presence. Perhaps it is more important to be present in relationships than to act present. It may be difficult to “pretend” presence because over time, true nature is often revealed. These findings are further confirmed by the work of Hewlett10 as revealed in Executive Presence. Communication rises to the top in determining the perception of presence. Because the nurse leader especially is under scrutiny in all professional interactions, how she/he speaks to people and how she/he behaves is most telling. Notice that the “how” is used here and not the “what.” Even when communicating difficult or distressing news, how it is communicated is the most important factor in how it will be received. A leader with authentic presence will communicate caring, compassion, and empathy because she/he will actually be caring compassionate, and empathetic.
APPLYING PRESENCE IN NURSING LEADERSHIP At Notre Dame of Maryland University, we have asserted that presence is a learning outcome of our academic program. Specifically, the master’s student in nursing administration is expected to create a practice environment for “being-with” staff, and other health care colleagues that reveals authentic nursing presence. Not only do the students acknowledge the meaning and importance of presence through the learning environment, but they are also prepared to incorporate presence with colleagues in their practice. This stems from our commitment to caring science,12 and is extrapolated from the area of The Art [of Leadership]: Leading the People as part of the AONE Nurse Manger Competencies.13 The research question is: how is presence imagined and portrayed through scholarly reflection by nursing administration graduate students at the end of their program? This study was approved by the institutional review board of Notre Dame of Maryland University. Capstone papers are written in the final semester reflecting on the program outcomes, one of which is presence. All graduates were invited to join the study, and 19 papers from students graduating between 2013 and 2016 were used. All were women, and most were Caucasian (63%). Professional roles come from a variety of practice settings and specialties, and included staff nurses, charge nurses/clinical coordinators,
October 2017
nurse managers, directors, hospital-based educators, and a quality improvement specialist. All narrative reflections submitted were included in the analysis. These were read multiple times in silence and aloud, which allowed the voices of each participant to emerge. Themes emerged through the text using the holistic-content perspective, as described by Lieblich,14 who states the text will “speak to you”14(p.62); that was my experience.
FINDINGS AND DISCUSSION Throughout the narratives were stories of struggle, bonding, and intention to incorporate presence into leadership practice. Overwhelmingly, the participants expressed increased awareness of and appreciation for the value of presence. This was illustrated in their recognition of the power of presence in building and sustaining relationships in clinical and leadership practice. Reflecting on their struggle, participants related their ability or inability to connect with patients by focusing on being-with someone in crisis, or taking a moment away from the business of patient care. One participant said: “Being with the patient is reduced to scrutinizing the patient’s chart and picking the brain of the [off-going] nurse for any information that may pertain to their care plan for the patient.” Another participant observed that it: “Becomes very easy to go through the motions of day-to-day living, but not really live out those moments.” To these participants, this focus on doing, but away from being, with the patient has been a source of frustration and dissatisfaction. Currently, the doing and the completion of tasks and activities is a sign of efficiency and hard work. In his seminal book On Caring, Mayeroff15 discussed the doing and not doing as an alternating rhythm, one of the ingredients of caring. He clarified that sometimes the “doing” is not active, but inactive. He continues: “In caring for a person…there are times when I do not inject myself into a situation, I do not take a stand one way or the other, I do nothing.”15(p.22) This act of doing nothing allows one to just be present. Prior to their experiences in an environment that fosters presence as a way-of-being, it has been something these participants have been unable to name or prioritize. Now, however they recognize the value in a new way and forged a commitment to incorporating this way-of-being into their leadership practice. Bonding was depicted as a palpable energy that brought the student groups together as a learning community, reduced anxiety and stress of their practice roles, and enhanced self-determination. The flow of energy was facilitated in part by using circle practice16 as a structure and way-of-being that helped them recognize and appreciate presence with each other, and by extension, with patients and colleagues. One participant said: “Once I checked-in to class, I felt like all of my stress of work, school, and life was left at the door. The act of checking-in gave the word ‘presence’ a new meaning for me.” As Baldwin and Linea16 explain, the check-in opens the circle and signifies the beginning of a different milieu. A group gathers socially, and checking-in signals the transition to learning/practice space. Although it only takes a few minutes, it marks this separation www.nurseleader.com
with the acknowledgment that we are all here for a purpose, and at least for a while, we can release the external stressors and focus on the work of the session/day. Some have incorporated this practice into their leadership roles. One participant has found this structure to be helpful in her model of shared leadership. She states: “I have now adopted this practice [circle] when I have my staff meetings, because I believe this method incorporates the value every person in the circle has on the discussion. I feel team members view the leader as a peer, instead of a superior figure.” The commitment of the participants surpasses the barriers identified that can prevent an environment that allows presence to emerge. In health care today, the busyness and chaos of changing and increasing regulations, payment structures, priorities, and fiscal realities can breed an environment of mistrust, competition, and haste that can be interpreted as uncaring, specifically from leaders. One participant said: “Being a leader takes a lot of effort, and making sure that you are purposely being present for your staff [can] take a lot of hard work, but I believe it is the difference between a good leader and a great leader.” Another participant takes responsibility for establishing an environment for others to learn and feel presence, and the power that results, saying: “While the program may have given me the tools for presence, I am given the opportunities to utilize [it] in my daily practice. As future nursing leaders, allowing our staff to be present is very important. The benefits I have gained from becoming more present and participating in reflective thought are vast and robust. Presence has allowed me to learn about myself and grow to be a better person and a stronger leader.” Another participant has elevated the importance of creating this environment to that of an expectation for herself as a nurse leader. She states: “If we expect our staff to be mindfully present with their patients and to demonstrate the development of therapeutic relationships, we must first set the standard in the relationships that we are establishing with our staff. It is essential that the nurse leader recognizes each employee as an individual and…consciously attempt to engage with each one of them on a personal level.” Incorporating presence into leadership practice is a goal for these participants because they have experienced this environment as pleasant. Like the professional role, the student role is hard work.Yet they made connections between an environment in which they feel present with others similarly engaged and an environment that feels safe, open, accepting, and allows them to experience vulnerability without repercussions. Creating this environment is essential to creating a culture of safety, identified by the Institute for Healthcare Improvement17 as a priority. A culture of safety involves trust, which can take some time and nurturing to establish. Taking that one extra moment to be present with someone could make the difference. One participant described this process: “Our circle flourished as we learned to trust each other and we created an environment where we felt safe. Our circle afforded us the time to make thoughtful, authentic contributions and a space for us to experience an authentic nursing presence.”
Nurse Leader
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Addressing the perceived connection to positive outcomes, one participant added: “Most importantly, I am cognizant of the fact that leaders who project a purposeful presence produce satisfied staff members. Then in return, engaged staff members produce happy, cared-for patients. It is an outright positive chain reaction.” Nursing presence and positive patient satisfaction are linked. After teaching nursing staff about enhancing presence and integrating techniques for the same, Penque and Kearney18 were able to show increased patient satisfaction item scores for courtesy and respect of nurses, and nurse listening. Both of these items were highly correlated to overall patient satisfaction.
LEADERSHIP IMPLICATIONS AND STRATEGIES Being present in relationships is a way of being that takes practice. In his book on expertise, Gladwell19 indicates that it takes 10,000 hours of practice to really be an expert at something. Whether it is becoming a nurse or being a leader, it takes time and effort for the skill to become second nature. By practicing being present with others, this will become a way-of-being in relationships. There are several ways to enhance presence as an individual and organizationally. For the individual, one way to enhance one’s ability to be more present in relationships is to incorporate mindfulness practice. Hahn20 offers meditative exercises that help one develop the ability to be aware of each moment as opposed to rushing through it. Examples can be as easy as clearing the mind by focusing on breathing. Just 10 to 20 minutes a day allows the body and mind to recharge. If sitting still is not achievable, many movement meditations exist such as Tai Chi, Qi Gong, or walking in nature. Even yoga or swimming in a quiet thoughtful place can be very meditative. Incorporating circle practice is another way to nurture the relationships of the team. The structure as outlined by Baldwin and Linea16 is adaptable for any group and can be used for staff meetings, huddles, or one-on-one conversations. The key is to focus on the relationships and really hear each other without interrupting or constructing rebuttal. Caine and Caine21 also translate a circle process using traditional business language that may be more palatable in some work-cultures. The most important practice to make presence authentic and believable is to walk the talk. If a leader expects nurses to be present with patients, but does not exhibit this practice with those same nurses, it will not be seen as a priority. The culture of presence needs to be modeled at all levels. One reason why the participants in this study were so aware and enamored with our culture is because it felt personal; they felt a sense of caring and belonging in this environment. The environment was modeled for them. They could see it, sense it, and feel that it was different, and they were determined to replicate this in their own organization. In “A Caring and Healing Environment,” Jayne Felgen22 talked about this as a critical foundation to creating a relationship-based care philosophy and delivery model. She says: “Initiating and sustaining therapeutic relationship with patients and their families is central to caring and healing environments. When nurses…own their practice and consciously create environ-
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ments of healing, their efforts visibly affect the practitioners [and] the practice.”22(p.24) Leadership rounding as described by the Institute of Healthcare Improvement23 is one way for the organization’s leaders to be present with staff and those in their care. Making these routine and useful includes asking questions and really listening to responses with an openness of hearing and addressing concerns. This cannot be done well with patronizing or superficial concern. Patients, families, and especially staff know when they are being given lip service. In these modern times of increasing communication through technology, it is easy to think that presence can only be achieved person-to-person. While still believing this is the best way, means to creating a caring healing environment using presence with technology exist. Use of e-mails, texts, tweets, and posts can do more than ask for extra shifts, remind about documentation, and beg for committee membership. Instead, sending virtual pats on the back, shout-outs, birthday greetings, and thank-you notes relate a caring message. Leaders’ communication, regardless of the means, in all their dealings with staff, peers, and members of the team is relayed through their actions.
CONCLUSION Patient experience, staff engagement, retention, and a myriad of other priorities all depend on relationships. Nurturing and sustaining relationships is the work of the successful leaders. Relating to people personally makes them feel important and valued. Whether the relationships are between the nurse and patient, manager and staff, or leaders to members of the community, taking time to be fully present is the essence of good communication. It takes intentionality and commitment to cultivate our own ability to be present especially because our world and industry is filled with many distractions. Creating a caring environment where being present is expected and relationships are valued is an honored goal and a recipe for organizational success. NL References 1. Twentieth Century Fox. Miracle on 34th Street [film]. Beverly Hills, CA: Twentieth Century Fox Home Entertainment; 1985. 2. Presence. Merriam-Webster online dictionary. https://www.merriamwebster.com/dictionary/presence. Accessed January 30, 2017. 3. Marcel G. The Mystery of Being. Volume I: Reflection and Mystery. South Bend, IN: St. Augustine’s Press; 1950. 4. Smith M, Turkel MC, Wolf ZR, eds. Caring Nursing Classics: An Essential Resource. New York, NY: Springer Publishing; 2013. 5. Watson J. Nursing: the philosophy and science of caring. In: Smith M, Turkel MC, Wolf ZR, eds. Caring Nursing Classics. New York, NY: Springer Publishing; 2013:143-153. 6. Swanson KM. Nursing as informed caring for the well-being of others. Image J Nurs Scholarsh. 1993;25:352-357. 7. Koerner JG. Healing Presence: The Essence of Nursing. New York, NY: Springer Publishing; 2007. 8. Dagley GR, Gaskin CJ. Understanding executive presence: perspectives of business professionals. Consult Psychology J Pract Res. 2014;66:197-211. 9. Turpin RL. State of the science of nursing presence revisited: knowledge for preserving nursing presence. Int J Hum Caring. 2014;18:14-29. 10. Hewlett SA. Executive Presence. New York, NY: HarperCollins; 2014. 11. Prestia AS. Existential authenticity: caring strategies for living leadership presence. Int J Hum Caring. 2016;20:8-11. 12. Hills M, Watson J. Creating a Caring Science Curriculum: An Emancipatory Pedagogy for Nursing. New York, NY: Springer Publishing; 2011.
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13. American Organization of Nurse Executives. The AONE Nurse Manager Competencies. 2015. http://www.aone.org/resources/ nurse-manager-competencies.pdf. Accessed March 12, 2017. 14. Lieblich A. Reading a life story from a holistic-content perspective. In: Lieblich A, Tuval Mashiach R, Zilber T, eds. Narrative Research: Reading Analysis and Interpretation. Thousand Oaks, CA: Sage; 1998: 62-63. 15. Mayeroff M. On Caring. New York, NY: Harper Perennial; 1971. 16. Baldwin C, Linea A. The Circle Way: A Leader in Every Chair. San Francisco, CA: Berrett-Kohler Publishers; 2010. 17. Institute of Healthcare Improvement. Develop a Culture of Safety. 2017. http://www.ihi.org/resources/Pages/Changes/DevelopaCultureofSafety.aspx. Accessed March 20, 2017. 18. Penque S, Kearney G. The effect of nursing presence on patient satisfaction. Nurs Manag. 2015;46:38-44. 19. Gladwell M. Outliers: The Story of Success. New York, NY: Little, Brown and Company; 2008. 20. Hanh TN. You Are Here. Boston, MA: Shambhala Publications; 2001. 21. Caine G, Caine RN. Strengthening and Enriching Your Professional Learning Community: The Art of Learning Together. Alexandria, VA: Association for Supervision and Curriculum Development; 2010. 22. Felgen J. A caring and healing environment. In: Koloroutis M, ed. Relationship Based Care: A Model for Transforming Practice. Minneapolis, MN: Creative Healthcare Management; 2004:23-52.
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23. Institute of Healthcare Improvement. Conduct Patient Safety Leadership WalkRounds™. 2017. http://www.ihi.org/resources/Pages/Changes/ ConductPatientSafetyLeadershipWalkRounds.aspx. Accessed March 22, 2017.
Mary O’Connor, PhD, RN, FACHE, is an associate professor at Notre Dame of Maryland University in Baltimore, Maryland. She can be reached at [email protected].
Please note: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The author reports no conflict of interest. 1541-4612/2017/ $ See front matter Copyright 2017 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2017.06.004
Nurse Leader
351
I
n a dramatic scene in the film Miracle on 34th
ly. According to Merriam-Webster,2 presence is
Street, the idealistic lawyer asserts that we
defined first as person-to-person physical presence,
should “not overlook those lovely intangibles, as
or in her/his direct vicinity, or being with a thing that
we’ll find out in the end they are the only things that
is “visible and concrete.” But more importantly,
really matter.” Presence is one of those intangibles,
another more elusive presence is “something (as a
an abstract concept that cannot be measured direct-
spirit) felt or believed to be present.”2
1
www.nurseleader.com
Nurse Leader
347
T
he philosopher Gabriel Marcel3 describes presence as a mystery. It is experienced, but difficult to put into words. In other words, presence is something that is “sensed.” It communicates knowing between 2 or more persons beyond physical closeness or the words spoken. Additionally, true presence can only be felt by the other. Marcel would challenge, for example, that I cannot be instructed or counseled into making my presence felt. It may be likened to a feeling of spiritual or emotional connection between people that is beyond the physical closeness. To further complicate this, the “feeling” of presence is often unconsciously taken for granted and most conspicuous in its absence. It is not difficult to ascertain if someone is physically present but attentively absent. The purpose of this article is to describe and illustrate the perspective and importance of presence for students completing a graduate program in nursing administration. In addition, strategies and implications of strengthening presence for nurse leaders are offered.
PRESENCE IN NURSING The connection between presence and caring is made through many scholars in the work of caring science.4 Most explicitly, presence as a necessary component of caring is visible in the theory works of Jean Watson5 and Kristin Swanson.6 In her Caritas Processes, Watson identifies presence directly: “Being authentically present and enabling and sustaining the deep belief system and subjective life world of self and one-being cared for.”5(p.256) Additionally, she implies the importance of presence in other phrases throughout these processes such as “intentional caring consciousness,” and “developing and sustaining a helping-trusting, authentic caring relationship.”5(p.256) Likewise, Swanson’s 5 caring processes include “being-with” the patient/family as the way in which understanding is created.6 She writes: “In many ways to be-with another is to give simply of the self and to do so in such a way that the one cared for realizes the commitment, concern, and personal attentiveness of the one caring.”6(p.355) In her seminal work, Healing Presence: The Essence of Nursing, Joellen Koerner7 calls being present with another an act of courage. It is the courage to learn, she says, as well as the curiosity and desire to engage in authentic relationship that is needed to deepen learning. She goes on to say: A nurse healer in the postmodern world creates an atmosphere of openness and safety, which invites compassion, clarity, and truth to enter. To effectively do this, the nurse must radiate her or his own soul qualities. A nonjudging presence invites those same qualities…This creates a shared environment that potentiates the self-healing capacity of both the person and the nurse.7(p.131) In order to be present and feel present with another person or even a group, there must be a connection. The environment must be conducive for this connection to occur allowing trust, caring, and vulnerability, in other words, a culture of safety.
348
Nurse Leader
LEADERSHIP PRESENCE Recently, there has been writing and research on executive presence. In one study done in Australia, the authors found several personal characteristics that influence people’s perceptions of their leaders’ presence.8 These include how the leaders present themselves physically, communicate (i.e., confidently and intellectually), use power, and their appearing to live their values or having integrity. In addition, although impressions were formed during initial interactions, in the end, they were based on whether or not the initial assessment stood over time. This is congruent with Turpin’s9 finding that presence is a process of acting. She states: “Leadership presence is outwardly focused on projection of image to achieve connections and followership, instead of the interpersonal connection itself.”9(p.16) Formal authority does not automatically confer true presence. Perhaps it is more important to be present in relationships than to act present. It may be difficult to “pretend” presence because over time, true nature is often revealed. These findings are further confirmed by the work of Hewlett10 as revealed in Executive Presence. Communication rises to the top in determining the perception of presence. Because the nurse leader especially is under scrutiny in all professional interactions, how she/he speaks to people and how she/he behaves is most telling. Notice that the “how” is used here and not the “what.” Even when communicating difficult or distressing news, how it is communicated is the most important factor in how it will be received. A leader with authentic presence will communicate caring, compassion, and empathy because she/he will actually be caring compassionate, and empathetic.
APPLYING PRESENCE IN NURSING LEADERSHIP At Notre Dame of Maryland University, we have asserted that presence is a learning outcome of our academic program. Specifically, the master’s student in nursing administration is expected to create a practice environment for “being-with” staff, and other health care colleagues that reveals authentic nursing presence. Not only do the students acknowledge the meaning and importance of presence through the learning environment, but they are also prepared to incorporate presence with colleagues in their practice. This stems from our commitment to caring science,12 and is extrapolated from the area of The Art [of Leadership]: Leading the People as part of the AONE Nurse Manger Competencies.13 The research question is: how is presence imagined and portrayed through scholarly reflection by nursing administration graduate students at the end of their program? This study was approved by the institutional review board of Notre Dame of Maryland University. Capstone papers are written in the final semester reflecting on the program outcomes, one of which is presence. All graduates were invited to join the study, and 19 papers from students graduating between 2013 and 2016 were used. All were women, and most were Caucasian (63%). Professional roles come from a variety of practice settings and specialties, and included staff nurses, charge nurses/clinical coordinators,
October 2017
nurse managers, directors, hospital-based educators, and a quality improvement specialist. All narrative reflections submitted were included in the analysis. These were read multiple times in silence and aloud, which allowed the voices of each participant to emerge. Themes emerged through the text using the holistic-content perspective, as described by Lieblich,14 who states the text will “speak to you”14(p.62); that was my experience.
FINDINGS AND DISCUSSION Throughout the narratives were stories of struggle, bonding, and intention to incorporate presence into leadership practice. Overwhelmingly, the participants expressed increased awareness of and appreciation for the value of presence. This was illustrated in their recognition of the power of presence in building and sustaining relationships in clinical and leadership practice. Reflecting on their struggle, participants related their ability or inability to connect with patients by focusing on being-with someone in crisis, or taking a moment away from the business of patient care. One participant said: “Being with the patient is reduced to scrutinizing the patient’s chart and picking the brain of the [off-going] nurse for any information that may pertain to their care plan for the patient.” Another participant observed that it: “Becomes very easy to go through the motions of day-to-day living, but not really live out those moments.” To these participants, this focus on doing, but away from being, with the patient has been a source of frustration and dissatisfaction. Currently, the doing and the completion of tasks and activities is a sign of efficiency and hard work. In his seminal book On Caring, Mayeroff15 discussed the doing and not doing as an alternating rhythm, one of the ingredients of caring. He clarified that sometimes the “doing” is not active, but inactive. He continues: “In caring for a person…there are times when I do not inject myself into a situation, I do not take a stand one way or the other, I do nothing.”15(p.22) This act of doing nothing allows one to just be present. Prior to their experiences in an environment that fosters presence as a way-of-being, it has been something these participants have been unable to name or prioritize. Now, however they recognize the value in a new way and forged a commitment to incorporating this way-of-being into their leadership practice. Bonding was depicted as a palpable energy that brought the student groups together as a learning community, reduced anxiety and stress of their practice roles, and enhanced self-determination. The flow of energy was facilitated in part by using circle practice16 as a structure and way-of-being that helped them recognize and appreciate presence with each other, and by extension, with patients and colleagues. One participant said: “Once I checked-in to class, I felt like all of my stress of work, school, and life was left at the door. The act of checking-in gave the word ‘presence’ a new meaning for me.” As Baldwin and Linea16 explain, the check-in opens the circle and signifies the beginning of a different milieu. A group gathers socially, and checking-in signals the transition to learning/practice space. Although it only takes a few minutes, it marks this separation www.nurseleader.com
with the acknowledgment that we are all here for a purpose, and at least for a while, we can release the external stressors and focus on the work of the session/day. Some have incorporated this practice into their leadership roles. One participant has found this structure to be helpful in her model of shared leadership. She states: “I have now adopted this practice [circle] when I have my staff meetings, because I believe this method incorporates the value every person in the circle has on the discussion. I feel team members view the leader as a peer, instead of a superior figure.” The commitment of the participants surpasses the barriers identified that can prevent an environment that allows presence to emerge. In health care today, the busyness and chaos of changing and increasing regulations, payment structures, priorities, and fiscal realities can breed an environment of mistrust, competition, and haste that can be interpreted as uncaring, specifically from leaders. One participant said: “Being a leader takes a lot of effort, and making sure that you are purposely being present for your staff [can] take a lot of hard work, but I believe it is the difference between a good leader and a great leader.” Another participant takes responsibility for establishing an environment for others to learn and feel presence, and the power that results, saying: “While the program may have given me the tools for presence, I am given the opportunities to utilize [it] in my daily practice. As future nursing leaders, allowing our staff to be present is very important. The benefits I have gained from becoming more present and participating in reflective thought are vast and robust. Presence has allowed me to learn about myself and grow to be a better person and a stronger leader.” Another participant has elevated the importance of creating this environment to that of an expectation for herself as a nurse leader. She states: “If we expect our staff to be mindfully present with their patients and to demonstrate the development of therapeutic relationships, we must first set the standard in the relationships that we are establishing with our staff. It is essential that the nurse leader recognizes each employee as an individual and…consciously attempt to engage with each one of them on a personal level.” Incorporating presence into leadership practice is a goal for these participants because they have experienced this environment as pleasant. Like the professional role, the student role is hard work.Yet they made connections between an environment in which they feel present with others similarly engaged and an environment that feels safe, open, accepting, and allows them to experience vulnerability without repercussions. Creating this environment is essential to creating a culture of safety, identified by the Institute for Healthcare Improvement17 as a priority. A culture of safety involves trust, which can take some time and nurturing to establish. Taking that one extra moment to be present with someone could make the difference. One participant described this process: “Our circle flourished as we learned to trust each other and we created an environment where we felt safe. Our circle afforded us the time to make thoughtful, authentic contributions and a space for us to experience an authentic nursing presence.”
Nurse Leader
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Addressing the perceived connection to positive outcomes, one participant added: “Most importantly, I am cognizant of the fact that leaders who project a purposeful presence produce satisfied staff members. Then in return, engaged staff members produce happy, cared-for patients. It is an outright positive chain reaction.” Nursing presence and positive patient satisfaction are linked. After teaching nursing staff about enhancing presence and integrating techniques for the same, Penque and Kearney18 were able to show increased patient satisfaction item scores for courtesy and respect of nurses, and nurse listening. Both of these items were highly correlated to overall patient satisfaction.
LEADERSHIP IMPLICATIONS AND STRATEGIES Being present in relationships is a way of being that takes practice. In his book on expertise, Gladwell19 indicates that it takes 10,000 hours of practice to really be an expert at something. Whether it is becoming a nurse or being a leader, it takes time and effort for the skill to become second nature. By practicing being present with others, this will become a way-of-being in relationships. There are several ways to enhance presence as an individual and organizationally. For the individual, one way to enhance one’s ability to be more present in relationships is to incorporate mindfulness practice. Hahn20 offers meditative exercises that help one develop the ability to be aware of each moment as opposed to rushing through it. Examples can be as easy as clearing the mind by focusing on breathing. Just 10 to 20 minutes a day allows the body and mind to recharge. If sitting still is not achievable, many movement meditations exist such as Tai Chi, Qi Gong, or walking in nature. Even yoga or swimming in a quiet thoughtful place can be very meditative. Incorporating circle practice is another way to nurture the relationships of the team. The structure as outlined by Baldwin and Linea16 is adaptable for any group and can be used for staff meetings, huddles, or one-on-one conversations. The key is to focus on the relationships and really hear each other without interrupting or constructing rebuttal. Caine and Caine21 also translate a circle process using traditional business language that may be more palatable in some work-cultures. The most important practice to make presence authentic and believable is to walk the talk. If a leader expects nurses to be present with patients, but does not exhibit this practice with those same nurses, it will not be seen as a priority. The culture of presence needs to be modeled at all levels. One reason why the participants in this study were so aware and enamored with our culture is because it felt personal; they felt a sense of caring and belonging in this environment. The environment was modeled for them. They could see it, sense it, and feel that it was different, and they were determined to replicate this in their own organization. In “A Caring and Healing Environment,” Jayne Felgen22 talked about this as a critical foundation to creating a relationship-based care philosophy and delivery model. She says: “Initiating and sustaining therapeutic relationship with patients and their families is central to caring and healing environments. When nurses…own their practice and consciously create environ-
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ments of healing, their efforts visibly affect the practitioners [and] the practice.”22(p.24) Leadership rounding as described by the Institute of Healthcare Improvement23 is one way for the organization’s leaders to be present with staff and those in their care. Making these routine and useful includes asking questions and really listening to responses with an openness of hearing and addressing concerns. This cannot be done well with patronizing or superficial concern. Patients, families, and especially staff know when they are being given lip service. In these modern times of increasing communication through technology, it is easy to think that presence can only be achieved person-to-person. While still believing this is the best way, means to creating a caring healing environment using presence with technology exist. Use of e-mails, texts, tweets, and posts can do more than ask for extra shifts, remind about documentation, and beg for committee membership. Instead, sending virtual pats on the back, shout-outs, birthday greetings, and thank-you notes relate a caring message. Leaders’ communication, regardless of the means, in all their dealings with staff, peers, and members of the team is relayed through their actions.
CONCLUSION Patient experience, staff engagement, retention, and a myriad of other priorities all depend on relationships. Nurturing and sustaining relationships is the work of the successful leaders. Relating to people personally makes them feel important and valued. Whether the relationships are between the nurse and patient, manager and staff, or leaders to members of the community, taking time to be fully present is the essence of good communication. It takes intentionality and commitment to cultivate our own ability to be present especially because our world and industry is filled with many distractions. Creating a caring environment where being present is expected and relationships are valued is an honored goal and a recipe for organizational success. NL References 1. Twentieth Century Fox. Miracle on 34th Street [film]. Beverly Hills, CA: Twentieth Century Fox Home Entertainment; 1985. 2. Presence. Merriam-Webster online dictionary. https://www.merriamwebster.com/dictionary/presence. Accessed January 30, 2017. 3. Marcel G. The Mystery of Being. Volume I: Reflection and Mystery. South Bend, IN: St. Augustine’s Press; 1950. 4. Smith M, Turkel MC, Wolf ZR, eds. Caring Nursing Classics: An Essential Resource. New York, NY: Springer Publishing; 2013. 5. Watson J. Nursing: the philosophy and science of caring. In: Smith M, Turkel MC, Wolf ZR, eds. Caring Nursing Classics. New York, NY: Springer Publishing; 2013:143-153. 6. Swanson KM. Nursing as informed caring for the well-being of others. Image J Nurs Scholarsh. 1993;25:352-357. 7. Koerner JG. Healing Presence: The Essence of Nursing. New York, NY: Springer Publishing; 2007. 8. Dagley GR, Gaskin CJ. Understanding executive presence: perspectives of business professionals. Consult Psychology J Pract Res. 2014;66:197-211. 9. Turpin RL. State of the science of nursing presence revisited: knowledge for preserving nursing presence. Int J Hum Caring. 2014;18:14-29. 10. Hewlett SA. Executive Presence. New York, NY: HarperCollins; 2014. 11. Prestia AS. Existential authenticity: caring strategies for living leadership presence. Int J Hum Caring. 2016;20:8-11. 12. Hills M, Watson J. Creating a Caring Science Curriculum: An Emancipatory Pedagogy for Nursing. New York, NY: Springer Publishing; 2011.
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13. American Organization of Nurse Executives. The AONE Nurse Manager Competencies. 2015. http://www.aone.org/resources/ nurse-manager-competencies.pdf. Accessed March 12, 2017. 14. Lieblich A. Reading a life story from a holistic-content perspective. In: Lieblich A, Tuval Mashiach R, Zilber T, eds. Narrative Research: Reading Analysis and Interpretation. Thousand Oaks, CA: Sage; 1998: 62-63. 15. Mayeroff M. On Caring. New York, NY: Harper Perennial; 1971. 16. Baldwin C, Linea A. The Circle Way: A Leader in Every Chair. San Francisco, CA: Berrett-Kohler Publishers; 2010. 17. Institute of Healthcare Improvement. Develop a Culture of Safety. 2017. http://www.ihi.org/resources/Pages/Changes/DevelopaCultureofSafety.aspx. Accessed March 20, 2017. 18. Penque S, Kearney G. The effect of nursing presence on patient satisfaction. Nurs Manag. 2015;46:38-44. 19. Gladwell M. Outliers: The Story of Success. New York, NY: Little, Brown and Company; 2008. 20. Hanh TN. You Are Here. Boston, MA: Shambhala Publications; 2001. 21. Caine G, Caine RN. Strengthening and Enriching Your Professional Learning Community: The Art of Learning Together. Alexandria, VA: Association for Supervision and Curriculum Development; 2010. 22. Felgen J. A caring and healing environment. In: Koloroutis M, ed. Relationship Based Care: A Model for Transforming Practice. Minneapolis, MN: Creative Healthcare Management; 2004:23-52.
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23. Institute of Healthcare Improvement. Conduct Patient Safety Leadership WalkRounds™. 2017. http://www.ihi.org/resources/Pages/Changes/ ConductPatientSafetyLeadershipWalkRounds.aspx. Accessed March 22, 2017.
Mary O’Connor, PhD, RN, FACHE, is an associate professor at Notre Dame of Maryland University in Baltimore, Maryland. She can be reached at [email protected].
Please note: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The author reports no conflict of interest. 1541-4612/2017/ $ See front matter Copyright 2017 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2017.06.004
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