Integrating Caring Theory With Nursing Practice and Education

JONA Volume 40, Number 11, pp 498-503 Copyright B 2010 Wolters Kluwer Health Lippincott Williams & Wilkins THE JOURNAL OF NURSING ADMINISTRATION Integrating Caring Theory With Nursing Practice and Education Connecting With What Matters Susan Dyess, PhD, RN Anne Boykin, PhD, RN Connie Rigg, MA, BSN Theory-based nursing practice positively influences many outcomes in healthcare organizations. As a response to limited human and economic resources, a college of nursing and a for-profit healthcare organization worked in partnership to develop a project that focused on developing and demonstrating the value of a dedicated education unit grounded in caring theory. The authors describe the development of the project, initial outcomes, and the relevance to nursing administration. Administrators and nurses are in a wonderful position to influence nursing practice through identifying concerns, addressing important questions associated with practice, and creating practice environments that ultimately improve the experience of being cared for (patient outcomes). Nursing theory provides the foundation for knowing and structuring and endeavors that influence practice. 1 Theorybased nursing practice guided by values and beliefs influence the manner in which nurses view their practice, organize themselves, communicate, interact, make decisions, and create an environment for nursing care to be delivered. In the past 22 decades, theoretical frameworks for nursing practice have been conspicuously identified and adopted by Authors Affiliations: Assistant Professor (Dr Dyess) and Dean and Professor (Dr Boykin), Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton; Director, Critical Care Service, St Mary s Medical Center, West Palm Beach, Florida (Ms Rigg). Corresponding author: Dr Dyess, Christine E. Lynn College of Nursing, Florida Atlantic University, 777 Glades Rd, CON 357, Boca Raton, FL 33431 (sdyess@fau.edu). DOI: 10.1097/NNA.0b013e3181f88b96 healthcare organizations that sought to address the requirements for the American Nurses Credentialing Center standards for Magnet A designation. 2 Consistently, nursing theoretical frameworks have been identified to positively influence nursing practice. Specifically, those grounded in caring science were affirmed through research to be responsible for improved and cost-effective patient care, enhanced communication and education, elevated professionalism, and the advancement of nursing research within healthcare organizations. 3-11 The process of implementing a caring framework called for the whole of a healthcare organization to understand the meaning of grounding nursing practice in caring values and its influence on the organization. 12 With the rising costs of healthcare, limited revenues, unfunded regulatory mandates, and uncompensated care, theory-to-practice initiatives may be difficult to actualize, but not impossible. 13 The process calls for innovation and collaboration. Interestingly, theneedforcollaborationtostrengthenthefocusof nursing in both education and practice is clearly called for and articulated by Benner et al. 14 This article highlights the development and initial implementation of a collaborative academic/healthcare research project in Southeast Florida that is focusing on demonstrating the value of having a dedicated education unit (DEU) grounded in a theoretical framework of caring to both nursing practice and education. With input from many participants that included nursing administration, staff, students, and faculty, this project was initiated in the midst of many constraining forces: the nursing shortage, the economic crisis, and the healthcare reform debate. These 498 JONA Vol. 40, No. 11 November 2010

constraints posed challenges that were recognized locally as well as nationally. Nonetheless, the project persevered and continues. Challenges Nurses as Resources The appropriate availability of competent and compassionate nurses as a human resource is itself an issue. The recent trends of nursing turnover, struggles, and costs associated with on-boarding of new nurses and an education-practice gap are formidable challenges receiving widespread attention from nursing executives. 13,15-21 Another challenge was the shortage of nurses. In Florida, the nursing shortage was predicted to reach 18,000 full-time-equivalent RNs in 2010. Nationally, it was reported that 41% of nurses currently employed in hospitals were not happily employed, and 22% of them planned to leave their positions within the year. 22 These data coupled with the rapidly increasing average age of practicing nurses and looming retirements increased the desire for the collaboration to positively influence practice and education. Economic Resources Exacerbating the human resource challenge were the economic instability and associated challenges faced by healthcare organizations. In a speech, Romer 23 noted that President Obama Bis urging healthcare reform to slow the growth rate of spending, tame the budget deficit, and provide all Americans with the secure health insurance coverage.[ Romer stated that despite the American Recovery and Reinvestment Act, during the first quarter of 2009 America lost nearly 700,000 jobs per month. Economic roadblocks and conditions such as these were not seen since the Great Depression of 1929. The financial restraints directly impacted the rate of reimbursement for healthcare rendered to those who had coverage as well those who were uninsured or underinsured. Additionally, the high jobless rates hovering at 10% together with the devastated regional real estate markets adversely impacted the ability to recruit experienced nurses from other locales to Florida. In response to the human and economic resource issues, the chief nursing officer of the healthcare organization was eager to engage in this project. A long-standing relationship between the healthcare and academic organizations existed that fostered the natural development of a collaborative project designed to address both the human and economic resource issues and the call for integrating nursing theory more intentionally with practice. Human and financial resources were pooled from the healthcare organization and academia for the project. The Project The design of the DEU was loosely linked to the concept described by others in recent published literature. 24 Conceptually, the Moscato et al 24 model was developed to address the demand for quality nursing practice settings that would accommodate nursing students and support nursing staff who were performing in highly stressful situations. Their model served as a guide for the evolvement of our unique model, which was intentionally focused on connecting baccalaureate, master, and doctoral nursing students, expert nurses, nursing leadership, and faculty to cocreate nursing practice grounded in caring theory. Nursing students experienced firsthand the living of theory-guided nursing practice, gained nursing practice experience in a for-profit community hospital, conducted research, and studied nursing with seasoned expert practitioners. The seasoned nurses had the opportunity to be revitalized by engaging in dialogue on caring theory, specifically Nursing as Caring (NAC), 25 and by intentionally reshaping their practice and that of the unit. This collaboration created excitement and growing commitment. Prior to undertaking this research project, the healthcare organization did not have a specific theory of nursing to guide practice. The selection of the NAC 25 was appropriate because it was congruent with the historical faith-based values and ideals of the organization. Most of the beliefs and values of the theory were relevant across disciplines and departments. The NAC grand theory provided key conceptual ideas for our collaborative team to elucidate and allowed for flexibility in actualizing the framework within nursing practice. Initial dialogue made explicit a call for a way of relating that was respectful and honored all persons. To align with the selected theoretical framework, we explored what Boykin and Schoenhofer 25 refer to as the Dance of Caring Persons 25(p37) (Figure 1). The image of a dance conveyed a way of being with others in which each person is known, respected, and valued. Everyone participating in the DEU was considered to be part of the dance and in the dance was understood to be a caring person who was contributing his/her unique gifts and talents to the project. Also, within the dance, each person offered his/her distinctive contributions as appropriate to his/her role as called for by the one nursed. The idea of a circle further implied that there was no hierarchy of positions but rather the recognition and celebration of the contributions of all involved. The many dancers in the JONA Vol. 40, No. 11 November 2010 499

Figure 1. Dance of Caring Persons. Boykin and Schoenhofer. 25(p37) DEU are reflected in Figure 2. This model was used as a dynamic guide for the unfolding research project. The dance came to represent the deliberate connecting of all persons involved in the care of those nursed. All staff members were invited on a weekly basis to share in dialogues of how they live caring uniquely in practice. The initial group was small and composed of committed nurse administrators, nurses, and staff. The small group met weekly to align expectations for the project and establish an understanding of theoretical concepts and overarching guidelines. Once the project was conceptually formed, appropriate institutional review board approval was acquired to ensure the ethical protection of all participants involved with the DEU. As the project took form, the initial small group grew as nurses, staff members, and students were again invited to join our Bcaring dialogues.[ Understanding the theoretical assumptions and important concepts of NAC 25 required time. Dialogue on this theory began about 4 months prior to the official initiation of the DEU. During this time, there were weekly gatherings with staff focused on connecting, valuing, reflecting, and dialogue on caring values. 26 Within the caring dialogues, we began to focus our thoughts on reflective knowing and appreciation of the caring knowledge embedded in stories of practice or nursing situations. The caring dialogue model is reflected in Figure 3. Caring intention was often related through dialogue as nursing situations were shared in moment-to-moment expressions of authenticity with all of the DEU collaborators. Caring was supported and known within one-to one conversations and group gatherings. Transformation had begun. Ultimately, the leadership of the DEU research project was under the direction of the chief nursing officer of the healthcare organization and the dean of the academic institution. In addition to their senior leadership, the practice setting clinical director and a project coordinator were involved. The project coordinator was a doctoral prepared nurse who acted as a liaison among members of the dance (Figure 2). Her responsibilities included day-to-day coordination, creating opportunities to further the understanding of NAC theory among staff and students, and serving as a role model. Other dancers in the model included a clinical instructor from the college who was responsible for coordinating and evaluating the student experience with the nursing practice mentors (staff nurses). The nursing practice mentors were expert staff nurses who committed themselves to the project and who were vested in the transformation of the nursing practice setting. The mentors provided modeling of clinical and technological expertise for the students. Additionally, the practice mentors were able to codiscover and live NAC, side-by-side with all members of the dance. Nursing as Caring Theory Much of what is known about caring in generic terms comes from the thoughtful work of Mayeroff. 27 In his scholarly work, he identifies Bingredients of caring[vknowing, alternating rhythm, hope, courage, trust, humility, patience, and honesty. These ingredients are useful in helping one to understand the ambiguous concept of caring as one is called to reflect on how each of these ingredients is lived uniquely every day. This understanding of living caring and knowing self as caring is the basis for knowing other as caring. From the very early stages of this project and continuing throughout, there has been a focus on coming to know self and other as caring and to appreciate unique expressions of caring. Figure 2. The many dancers in the dedicated education unit. 500 JONA Vol. 40, No. 11 November 2010

Figure 3. The Nursing as Caring practice model. The theoretical lens of NAC asserts that the focus of nursing is Bnurturing persons living and growing in caring.[ 25(p12) The theoretical assumptions of NAC are listed in Figure 4. Weekly semistructured dialogues among project members focused on understanding these assumptions and key conceptual ideas inherent to NAC. One central concept is that of the nursing situation. Boykin and Schoenhofer 25 believe that the knowing of nursing is embedded within the nursing situation, which is defined Bas a shared lived experience in which the caring between nurse and nursed enhances personhood.[ 25(p13) Reflection upon nursing situations of practice provided exquisite opportunities for uncovering the knowledge and essence of caring in nursing. The nurses intentional presence in these situations allowed for calls for nursing to be heard and responded to in a person-focused way. As professionals and nonprofessionals shared their important stories, unique gifts were illuminated and illustrated how each person lives caring uniquely within the organization. Knowing and valuing others associated with nursing situations created, maintained, and supported a caring environment. Nursing situations written by undergraduate students and nursing staff were shared in weekly gatherings. The situations shared focused on the person(s) nurses but often involved many that included administrators, nurses, staff members, nursing practice mentors, and nursing faculty. One example of a shared nursing situation was complex and centered on a harried code-blue response for a woman living with numerous chronic conditions. The code-blue event occurred during the time of shift change, and it was chaoticandrepletewithemotions.thecaringdialogue within the DEU was able to facilitate understanding perspective of students, nurses, and staff. Reflections on this nursing situation provided opportunity to know how caring was lived compassionately and uniquely. The transformation of perceptions for the code-blue event that occurred reveals that in the midst of chaos and unfortunate but inevitable patient outcomes, caring can be recognized and celebrated. The caring dialogue also demonstrated that the knowledge gleaned from the study of a nursing situation and a focus on shared values strengthen the understanding of living and practicing caring. Another essential NAC 25 concept that had great meaning for the project participants was Bdirect invitation.[ Although the intention of this concept is related to the nurse coming to know the person nursed as caring by inviting him/her to help the nurse to know what matters most to him/her in the moment, the staff expanded the use of this concept to identify what matters most to them as dancers in the circle. It was recognized that an important concern for nurses was a desire to create a work environment reflective of caring values and to consider a journey toward Beacon recognition. 28 Their hope for future was to be recognized as a Beacon unit by the American Association of Critical-Care Nurses. On a number of levels, all members of the dance appeared to be committed to creating a practice environment grounded in NAC and to advancing the goals of the DEU. Outcomes Elements of transformation are already notable in the healthcare organization. These initial outcomes are the by-products of initiating a collaborative project Figure 4. Major assumptions of Nursing as Caring. JONA Vol. 40, No. 11 November 2010 501

that links a healthcare organization and an academic institution. These initial outcomes are the transformative changes in the nursing practice environment that now exist when they did not exist prior to our DEU. They include (a) a growing appreciation for knowing self and other as caring; (b) a cadre of clinically seasoned and dedicated staff nurses who support the advancement of theory-based professional nursing care rendered to patients; (c) committed members of an administrative team and expert nurses eager to mentor staff and promote theorybased quality care as they embark upon a journey toward Magnet recognition; (d) dedicated educators on the DEU who model the living of theory-based practice with students in all programs of study; (e) inspired student nurses seeking employment within the DEU; (f) a theoretical model using NAC for advancing efforts toward the journey of Beacon recognition; and (g) an opportunity to support the transition and on-boarding of new nurses into the critical care environment is enhanced. Lessons learned from this project have significant implications for nurse administrators. The role of nurse administrator is directly linked to an understanding of nursing as a practice discipline. When the practice of nursing administration is grounded in NAC, it is understood that all activities are ultimately directed to care for persons nursed. The role of the nursing administrator in the Dance of Caring Persons is to create, maintain, and support Ban environment in which calls for nursing are heard and nurturing responses are given.[ 25(p33) The nurse administrator is committed to hearing the stories of nursing practice to secure resources essential to the goals of nursing, grounding the organization in caring values, and communicating nursing s unique contribution. the healthcare environment; other nursing professionals in other communities are also involved with this important work. 8 The presented DEU model connected caring theory with the practice and educational arms of nursing. This model merged the strengths of experts in practice settings with the experts in academic settings, resulting in synergies that allowed cocreation, transformation, and an expanded understanding of theory linked to nursing practice. For our particular DEU, the effectiveness of the project will continue to be measured in multiple ways at the 1- and 2-year points of the project. Preproject measurements were taken with 3 tools: the Caring Behaviors Inventory 24, 29 the Horizontal Violence Survey, 30 and Healthy Work Environment Measure. 28 Postproject measurements have not yet been done. Other preproject and postproject measures include the vacancy and retention rates as well as the healthcare organization s own standardized nursing satisfaction scale. Focus groups and interviews with members of the dance are also being conducted to better understand the experience of living caring in practice. As our understanding of nursing education, 31 nursing practice, 4-7 and integration of theory 3 is supported, the DEU is unfolding. This project demonstrates the value of implementing caring theory within a healthcare organization for nursing administrators, expert nurses, nursing faculty, students, and new nurses. Our DEU project has begun, and the efforts are important steps to advancing the reality of theory integration. Felgen 8 states, BCaring has its greatest value when it lives in the organization, in daily interactions, in job descriptions, and performance appraisals, and is most precious when it is seemingly invisible.[ 8(p214) Summary Research findings that integrate caring within practice inspired our innovative design of the DEU in Acknowledgment The authors thank all members of the DEU dance for their collective contributions. References 1. Sumner J. The foundation of advanced practice nursing. Top Adv Pract Nurs. 2005;4(4):1-3. 2. American Nurses Credentialing Center. Magnet Recognition Program Application Manual. Silver Spring, MD. American Nurses Credentialing Center; 2005. 3. Birk L. The Magnetism of theory: resonance to radiance. JONA. 2007;37(3):144-149. 4. Boykin A, Bulfin S, Baldwin J, Southern R. Transforming care in the emergency department. Top Emerg Med. 2004; 26(4):331-336. 5. Boykin A, Bulfin S, Schoenhofer S, Baldwin J, McCarthy D. Living caring in practice: the transformative power of the theory of nursing as caring. Int J Hum Caring. 2005;9(3):15-19. 6. Boykin A, Schoenhofer SO. The role of nursing leadership in creating caring environments in health care delivery systems. Nurs Adm Q. 2001;25(3):1-7. 7. Boykin A, Schoenhofer S, Smith N, St Jean J, Aleman D. Transforming practice using a caring based nursing model. Nurs Adm Q. 2003;27(3):223-230. 8. Felgen J. Caring: core value, currency, and commodityi is it time to get tough about Bsoft?[ Nurs Adm Q. 2003;27(3): 208-214. 502 JONA Vol. 40, No. 11 November 2010

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