eric135

A meeting with Jean Watson... 2 stars out of 4...

Jean Watson spoke at our hospital the other day.

I had worked the night before, and my shift ended at about 0630am, but the meeting wasn't scheduled until 8a. So I spent more than an hour sitting in my car, parked in the employee parking deck, watching Rachel Maddow shows on my iPod.

The meeting was packed, with about 50 nurses attending. All of us were either charge nurses or clinical directors with a few clinical educators mixed in.

I think Jean Watson thought all of us were well-versed in her theory, and that everyone in the room was accustomed to the spiritual, metaphysical and existential nature of her work. I don't think she realized that very few of the nurses attending were very familiar with her book. Thus it surprised me when, with very little by way of introduction or preparation, she proceeded with a meditation exercise. She brought out a "singing bowl" very similar to the one pictured here, and she rubbed the rim with the stick which caused the bowl to resonate.

I've never been very good with meditation. I've tried several times to meditate and I just can't do it. So while everone else in the room bowed their heads and closed their eyes, I started to get a serious case of... the giggles.

To stop myself, I started calculating the Fibonacci sequence of numbers in my head.

Not a great beginning.

It's not that I don't believe in the theory. I do think it is important to appreciate our patients as a total, unique, spiritual, significant human being, and not simply a machine. That's something I can get behind.

But I was sort of hoping the meeting would be more of a "hands on" session, with all of us charge nurses discussing how to actually use the theory.

• What specific behaviors would be seen when observing a nurse that is well versed in the theory?
• What sort of verbalizations should be used? In other words, what needs to be said?
• How do you document use of this theory?
• How do you use the theory if your background and comfort zone is more scientific / numerical / logical / empirical?
• As a charge nurse, with scientific background/personality, how can I teach or model this theory for my nurses?

We didn't really go into that at the meeting. In fact, at one point, one of the nurses finally simply asked Jean Watson to go over the 10 Caritas Processes, to which she surprisingly replied, "Wow I'm not sure I can do that, I'm not sure _I_ even know them."

One of the nurses handed her a copy of her book, after which she did give a pretty good review of the basic concepts, but I was still taken aback that she didn't know her own material well enough to cite them from memory (although she did admit that she planned to do a more thorough discussion of the theory in a more general-audience meeting later in the day).

I guess if I had to rate the meeting, I'd have to give it 2 stars out of 4.

Jean Watson: Caring Theory of Nursing... Caritas Processes...

Updated 3/14/2009

   Our hospital network is adopting Jean Watson's Caring Theory of Nursing.

Most nursing theories are based on Nursing as a humane and compassionate application of a scientific method. Jean Watson encourages us to "return to our core values", and recall the "original reason we all went into nursing", things we as nurses tend to forget when carrying out the "clipboard nurse" type of nursing, where we exhaustively collect data in the form of measurements and numbers. Watson asks all of us as nurses to be more "in tune to the moment" when interacting with our patients (she doesn't like the "customer" model of the modern hospital), and realize that our interactions can be more humane, significant, and caring.

Nursing, as the underling of the medical profession, often works to turn the human being into the human body, further breaking him/her down into just a "body", and eventually just a "machine."

Nursing work too often focuses on "doing" rather than "being", and has become too easy to "do something" to a machine, things we would never consider doing to a human being.

Watson describes ten "Caritas Processes". Originally "Carative Factors," she redefines these essential "core values":

Formation of humanistic-altruistic system of values, becomes: "Practice of loving-kindness and equanimity within context of caring consciousness

Instillation of faith-hope, becomes: "Being authentically present, and enabling and sustaining the deep belief system and subjective life world of self and one-being-cared- for";

Cultivation of sensitivity to one's self and to others, becomes: "Cultivation of one's own spiritual practices and transpersonal self, going beyond ego self";

Development of a helping-trusting, human caring relationship, becomes: "Developing and sustaining a helping-trusting, authentic caring relationship";

Promotion and acceptance of the expression of positive and negative feelings, becomes: "Being present to, and supportive of the expression of positive and negative feelings as a connection with deeper spirit of self and the one-being-cared-for";

Systematic use of a creative problem-solving caring process, becomes: "creative use of self and all ways of knowing as part of the caring process; to engage in artistry of caring-healing practices";

Promotion of transpersonal teaching-learning, becomes: "Engaging in genuine teaching-learning experience that attends to unity of being and meaning attempting to stay within other's frame of reference";

Provision for a supportive, protective, and/or corrective mental, physical, societal, and spiritual environment, becomes: "Creating healing environment at all levels, (physical as well as non-physical, subtle environment of energy and consciousness, whereby wholeness, beauty, comfort, dignity, and peace are potentiated";

Assistance with gratification of human needs, becomes: "assisting with basic needs, with an intentional caring consciousness, administering ‘human care essentials', which potentiate alignment of mindbodyspirit, wholeness, and unity of being in all aspects of care"; tending to both embodied spirit and evolving spiritual emergence; Allowance for existential-phenomenological-spiritual forces, becomes: "opening and attending to spiritual-mysterious, and existential dimensions of one's own life-death; soul care for self and the one-being-care-for.

 

Our new Clinical Director gave all of us Charge Nurses a copy of Watson's book, which I dutifully read and attempted to absorb over a weekend.

It's going to be a challenge for me. I've never been that "spiritual" or "metaphysical", instead relying on my scientific background thoroughly grounded in skepticism and empiricism. A lot of these carative factors / Caritas Processes are difficult for me to understand on anything more than an intellectual basis. In other words, I have been unable to bridge the gap between vocabulary and meaning.

Jean Watson is scheduled to come to our hospital tomorrow, and I'll be meeting with her along with other charge nurses throughout the hospital in a 90-minute presentation.

Links:

Jean Watson's information page from the University of Colorado Denver.

The Watson Caring Science Institute's page.

From RNJournal.com, a good overview.

Search Query Results from PubMed.

A Pragmatic View of Jean Watson's Caring Theory.   A Word document giving a general review of Watson's Theory and a case study of its implementation.  (Viewer).

 

 

Learn to Like the Boss? Oh I don't know...

I read the Investors Business Daily newspaper from cover to cover every day. I like to read the section where they review the 10 Secrets to Success. Today's section was given the title, "Learn to Like the Boss." I'm not sure I agree with all of it, only due to specifics of the nursing industry (where nurse leaders simply do not have as much control over matters of compensation.) I recognize there are sacrifices I am making in terms of getting management positions at one specific hospital, but I don't care to leave the bedside anyway, and they simply can not beat my care because my care is simply excellent. But there is a section where it talks about following the heirarchy, and warns that members of that heirarchy will work against anyone threatening that hierarchy because they "have to." Hadn't considered that, really.

Learn to LIke the Boss
from www.investors.com

Work... The Matrix...

I have been working a lot of extra hours at work. Obviously, a lot of my motivation is the upcoming Christmas Holiday, but I've been putting in a lot of consectutive days because I notice I have been sleeping better. When I split my days off, I end up spending the days in between laying in bed trying to get to sleep. It has been so nice going to bed in the morning with that tired sleepy feeling, where the bed really feels GOOD. The past couple of days, I've been waking up in the same position I fell asleep in. It's too bad my knees get to be so painful after three or four 12-hour shifts.

I still get pretty angry at work about the poorly managed changes, but I have been trying out something new. I have been placing all of my charting materials on a rolling cart, which I move from one room to the next. When I chart, I push my rolling chair near my patient's rooms. I was doing this originally to get away from the noise and constant interruption at the nurses' station. But I find my nursing is a lot more intensive. Sitting within direct view of all of my patient call lights has saved a lot of steps, since my patients' charts are just a few steps away instead of at the nurses' station. I also have noticed my patients have been a lot happier, knowing I'm right in front of their room. I have not done any time studies yet, but I am certain my patients don't call out as often, confident that I will make an appearance soon anyway. Also, being away from where everyone is sitting has given me the chance to really concentrate on nursing, which makes me feel good.

I've been working more on those Patient Problem Lists I mentioned earlier. I've been using them in my verbal report, so that the oncoming nurse is given a brief summary of every DRG/medical diagnosis, and every physician/nursing order related to each medical diagnosis. Even if no one cares to make it a standard of practice, I plan to continue writing these lists out, so that no one can claim I have not passed on important details in an often rushed and hurried verbal report. There's been some talk of me teaching others how to fill out these forms, but I don't hold out much hope that the average nurse will want to spend the time working on them, even though they make nursing practice more comprehensive.

On a weirdly aside note, I've had the opportunity to watch the Matrix Trilogy several times these past couple of weeks. My favorite scenes:

• In Matrix Reloaded, I love the scene where Neo fights with the "old programs" that were working for the Merovingian. I, for whatever reason, get a big kick out of that Asian girl. She was just so relentless.
• In Matrix Revolutions, I love that scene where Neo and Trinity are making their final approach to the machine city, and while under attack, soar above the clouds and into the bright sun. It's very inspiring, even though the ship immediately sinks once again in the harsh bleak darkness of the real world.
• Again in Revolutions, I like the scene where that young guy takes control of that fighting machine. He aims his guns at a gate he must open. Just before he fires, he says something like, "Neo... I believe!!"
• Again in Revolutions, at the very last scene, when Seraph asks The Oracle, "Did you always know?"  and the Oracle replies, "Oh, no. No, I didn't. But I believed... I believed!!"

Vision and Goals

The problem is... most nurse leaders don't really have a Vision. They have grandiose ideas about what they want to do with their clinical area, but if they don't meet their goals, most nurse leaders fail miserably in identifying where the problem is, how to address the problem, and then working toward fixing the problem.

On the other hand, good leaders are able to identify new (or at least revised) goals, all toward the original Vision Statement. So if a leader's assigned clinical area is not "perceived as a best place to work by nurses," then everyone gets together as a work group to identify WHY it isn't so. Have we identified the wrong goals? the wrong problem? Does everyone believe in the leadership's ability to get the group to the goal?

What happens in nursing today is that major changes are made, usually with no Vision Stement, or even a properly written Goal Statement (for me, the difference between a Goal and a Visioni is that Goals are behavioral and need to be MEASUREABLE in order to be evaluated. Visions are not necessarily so. I think forward-thinking leaders use both effectively.

We have neither. Big changes are made and the bedside nurse has no idea why the change was made, if there is something leadership is trying to accomplish, and without knowing what that is, the bedside nurse is left in the dark and can't even provide feedback on what might work better.

My God What Are THese Crazy Heads About?

Someone let me know via email that this site is the primary Google hit for "Nursing Collaboration." I am appalled, considering my failure in this endeavor.

Earlier today, I attended a leadership meeting where we discussed how the new change-of-shift process was discussed. It really was a pep-rally of supporters for the verbal face-to-face report method.

I was very unpopular.

Everyone keeps citing research that shows how verbal reports are more effective than taped reports. Everything I can find is anecdotal, and has been written by old nurses no longer at the bedside. These are nurses that don't have email, who think blogs are weather phenomena, and whose VCR's perpetually flash "12:00." These are not new young nurses, who do most of their information gathering via non-face-to-face media, such as the internet. If you're a nurse, and can send me the PubMed PMID for some quantitative non-emotive research that says patients get better care with all the nurses tied up at the nurses' station for an hour two or three times a day, I challenge you to send that PMID to me.

Idiots.

My thoughts on a failed project regarding nurses and web usability...

I am mature enough to realize that some of the projects I introduce will fail. Over the past four years at the hospital where I work, I’ve introduced many successful projects, especially when my efforts were engaged for the current bid for magnet status. But sometimes, they don’t take off. Sometimes, they die horrible deaths. I think it’s important to just realize this and move on.

I’ve always thought nurses could do their jobs easier and faster if they would utilize the power of the computer to do their work. I wasn’t really talking about medical recordkeeping (although this is important, I don’t think it’s revolutionary). I’m talking about the utilization of computer technology to move nurses away from doing their business in real time, and moving them toward doing some of their tedious work in virtual time, using message boards, blogs, wikis, etc.

My idea was that, since so much of nursing has to happen in a group setting, and since this group effort has historically happened in real time meetings, it would be beneficial to make it so that nurses didn’t have to meet face to face. They could meet virtually, collecting and comparing data, setting agendas, distributing documents, all in the background with discussion. Then, if needed, more effective real-time meetings could happen.

With this added efficiency, the number of real time meetings could be reduced. This could be a real benefit to our industry because hospitals can not be shut down during a specified meeting time. The patients are still there (and still coming), which means most of the leading nurse clinical leaders are not able to attend meetings (because they are too busy taking care of patients.) This means that most critical meetings are happening between people that are not associated with bedside care, and who do not know (or do not remember) what the bedside environment is like.

So I (with lots of help from my sister, Karen) set up a php-based message board for our unit. My plan was to get all of the committee members, clinical nurse leaders, and other members of nurse leadership to write their thoughts. They could update the floor on what the various committees are up to. They could receive input from floor nurses. They could provide evidence-based practice by disseminating articles and websites of interest.

I presented the message board to our Shared Leadership committee. I set up an internet connection to an overhead projection of the message board, and illustrated its use. It was one of the most powerful and well-received presentations I’ve ever given (and I give them a lot), and everyone wanted to get on board. It was exciting. The head of nursing wanted to initiate a discussion with our IT department to set up servers that could run the php board securely. Everyone wanted in. I proudly patted myself on the back, ready to sit back and Watch Everything Change Forever.

Some things I did not anticipate:

1. My Brother-in-Law, Adam, had been harping on me to get a firm grip on what the message board was going to DO for the nurses, and get a good background on web usability. I did not do this nearly enough.

2. Unlike most modern industries, you can be a great nurse and not know SQUAT about computers. In fact, some of the best nurses I know do not have an email address (which, for me, would be like living without running water or electricity). What I mean is, there is no base of computer knowledge that I could depend on. Unlike corporate life, or life in the finance industry, or IT, or higher education, you simply do not need to be good at computers to provide good patient care. So there is no push to “get good at computers” without doing more work on #1 above.

3. Related to #2, you do not need good writing skills to be a good nurse. Contrary to my own self-centered thinking, you don’t need to write a blog, or engage in public speaking, or come up with new documents to be in nursing. So writing for a message board is not necessarily going to be the biggest item on your list of Nursing Things To Do. I could not get any of the committee chairpersons to write for the message board. My requests for committee information usually took the form of a forwarded email with an attached .doc file of the last meeting minutes (which is not what I wanted – I wanted something more personal to get nurses involved, not some dry meeting minutes).

4. I did not have a strong enough relationship with my clinical director to support my project. Well, to put it mildly, we hate each other. So my latest pearl project wasn’t going to go anywhere if it was going to ride on this crazy woman’s back. I should have known that.

So I’ve learned some good lessons. First and foremost is that I presently lack the sort of intimate understanding of people (specifically nurses) to assess their needs, assess their desires to get these needs met, and to meet them.

Probably more training is involved. I’m not sure how much more I’ll do. I’m not of the mindset to be a consultant (and have earned a new respect for good consultants). I think I could go out and learn it, but I’m not sure the information would ever be properly financially reciprocated (this happens a lot in nursing; it drains intelligent and innovative minds out of nursing; it makes it more likely you will die in a hospital bed due to the bad clinical judgment of an unimaginative and unintelligent nurse).

My next project is more commiserate with my skills as a former teacher. I’m working on learning/behavioral objectives for our nurse extern program. If you’re a teacher, I’m thinking something along the lines of the SOLs (Standards of Learning) used in grade school. Sort of a Bloom’s Taxonomy but for people trying to be nurses. Wish me luck.

Still looking...

So my trip to the bookstore was a bit of a bust. I went to the ridiculously huge Barnes & Noble at Desert Ridge Mall. Of the ones on my list, the only book they had in stock from my list was Jakob Nielsen's Designing Web Usability. It was an interesting read, and instead of purchasing it, I read it almost cover-to-cover while seated in a cumfy chair at the back of the store. It was mostly about the specifics of making truly useful web pages, where usefulness and ease of use was more important than the appearance. I learned a lot.

But it wasn't what I was looking for. I wanted to find a book about how large groups of people use a corporate web site to coordinate their efforts, and to disseminate information effectively. My conclusion must be that this book simply hasn't been written yet.

In a way, I guess I'm glad. I sometimes prefer a creative challenge that is not hindered by an environment full of "this is the standard" or "this is what everyone expects out of this." Sometimes, it's nice to just start the design process at the basement level, and work my way up.

I've done it before, in a previous life as a high school teacher. But this challenge is different. I lack a true knowledge base of computer knowledge to figure out how to get from my ideas to a finished working project (that nurses really will use).

Web usability...

I've been to another Shared Leadership meeting (part of our ongoing bid to be a Magnet hospital), and one of the topics was how to conduct more effective meetings. The problem, simply put, is that there are so many meetings that are scheduled, that nurses are overwhelmed, and so attendance at the meetings are poor, or their productive output is low.

I've complained about this very thing before. My thoughts are that there are very few meetings that happen which actually put out any product that helps get the job done better, faster, more efficiently or at a lower cost. Most hospital meetings end up being gripe/bitch sessions, and everyone in attendance agrees or disagrees. Possibly some change in policy is worked out, but information from these meetings is never effectively communicated to the floor-nurse level. There are grandiose plans and well-intended efforts, but the floor-nurse is left completely out of the loop.

It doesn't matter if you publish the meeting minutes. No one ever reads them, or if they do, there is not a coordinated effort to translate the cogitations of a meeting into a workable plan.

There are now discussions about having a series of meetings, the topic of which will be the improvement of meetings. Great.

My next big project will be some sort of effort on my part to bring nursing into the 21st century. The corporate world has already made a complete dissection and analysis of this very problem, and have realized that the answer lies in computer technology. Specifically, I'd like to work on getting nurses to use the computer and internet to work together in a virtual, rather than real-time, manner. Here are the advantages, as I see them:

1. It would be possible to have fewer meetings, or at least more productive meetings.

2. More people could participate in the process of Idea Development, especially nursing exemplars, many of whom are not interested in attending meetings.

3. Nurses can network more effectively with one another, so that similar committees can exchange information from one floor/department to another.

4. An intranet interface could bring the ideas out of the committees, and directly to the floor nurse for potential use or modification.

5. Ideas can be warehoused within the facility. Properly indexed and searchable, this repository of knowledge can become available to individual floor nurses with an inter/intranet connection.

6. Ideas can be maintained even after key personnel either discontinue their presence on the committee, or even after they have terminated employment or retired.

7. A document server can be developed so that documents can be developed over the internet, with input available from all personnel.

8. An online spreadsheet functionality can be designed so that data collection from all areas can be entered, tabulated, and stored for review (think Quality Assessment and Continuous Quality Improvement data here).

I was discussing this issue with my sister, Karen, and I find that my knowledge of computers, while formidable on a personal level, seem woefully inadequate in dealing with larger groups of people. I feel the need to go to our IT department, have them install software on our intranet, and crank up a corporate blog, a large network of message boards, and expect every floor nurse to just jump in there and start typing away at their computers, as though born and cut their teeth on Tech TV. I see now that the job will be a long-term and gradual one, with an ongoing effort to bring nurses and CPUs together in a meaningful and productive way.

Well, at least I've come up with a first step - research. I have gone to Barnes and Noble and Borders Books and perused the computer books, but without knowing a topic or subject, I wasn't able to figure out what I needed to read. Again, Karen to the rescue. I'm heading out tomorrow to look at books on "Web Usability." I utilized the phrase in a search on Amazon dot com, and came up with quite a number of texts. Hopefully, a few of them will be on the shelves when I go. My reading list so far:

Designing Web Usability: The Practice of Simplicity, by Jakob Nielsen

The Elements of User Experience: User-Centered Design for the Web, by Jesse James Garrett

Web Usability for Dummies, by Bud Smith, Bed E. Smith, Richard Mander

Usability Business: Making the Web Work, by Bawa, Trenner and Dorazio

I've been to Microsoft's Sharepoint site, and it looks like something we could use. It looks pricey, though. I'm not sure how the number of users may impact the cost (it looks significant) but we're talking $2K, at least.

Any input on this subject, please leave a comment or send me some email.